Basic Information
| Provider Information | |||||||||
| NPI: | 1093944068 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEDGE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | REAHANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S, ED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2167 BALMER RD | ||||||||
| Address2: | |||||||||
| City: | RANSOMVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141319785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165311293 | ||||||||
| FaxNumber: | 7162970998 | ||||||||
| Practice Location | |||||||||
| Address1: | 2167 BALMER RD | ||||||||
| Address2: | |||||||||
| City: | RANSOMVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141319785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165311293 | ||||||||
| FaxNumber: | 7162970998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2009 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1237083 | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 1237083 | 01 | NY | NYS LICENSE | OTHER |