Provider Demographics
NPI:1174064877
Name:BERZON, ALISA (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:BERZON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-2501
Mailing Address - Country:US
Mailing Address - Phone:443-602-1594
Mailing Address - Fax:
Practice Address - Street 1:2607 SMITH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-2501
Practice Address - Country:US
Practice Address - Phone:443-602-1594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04501235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist