Provider Demographics
NPI:1871157511
Name:WODZANOWSKI, LAUREN JEANNINE
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:JEANNINE
Last Name:WODZANOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1809
Mailing Address - Country:US
Mailing Address - Phone:718-853-1884
Mailing Address - Fax:718-853-5883
Practice Address - Street 1:5601 16TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1809
Practice Address - Country:US
Practice Address - Phone:718-853-1884
Practice Address - Fax:718-853-5883
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199555081235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist