Provider Demographics
NPI:1144516188
Name:BAZZANELLA, MARC DOMINIC
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:DOMINIC
Last Name:BAZZANELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PLEASANT OAK CT
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-3225
Mailing Address - Country:US
Mailing Address - Phone:831-278-0465
Mailing Address - Fax:
Practice Address - Street 1:4502 MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-2133
Practice Address - Country:US
Practice Address - Phone:608-249-2137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5218-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist