Provider Demographics
NPI:1245725423
Name:MAZZONI, OTTO III (MS, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:OTTO
Middle Name:
Last Name:MAZZONI
Suffix:III
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 WHISPERING PINE TRL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:75457-4957
Mailing Address - Country:US
Mailing Address - Phone:903-563-2405
Mailing Address - Fax:
Practice Address - Street 1:2407 W MAIN ST # 82
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426-3327
Practice Address - Country:US
Practice Address - Phone:903-427-3821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111590235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty