Provider Demographics
NPI:1578364261
Name:MOURITZEN, KOSTANDINA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KOSTANDINA
Middle Name:
Last Name:MOURITZEN
Suffix:
Gender:
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 1:102 CELEBRATION BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-3528
Mailing Address - Country:US
Mailing Address - Phone:718-697-9787
Mailing Address - Fax:
Practice Address - Street 1:102 CELEBRATION BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-3528
Practice Address - Country:US
Practice Address - Phone:718-697-9787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01207400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist