Basic Information
| Provider Information | |||||||||
| NPI: | 1124145644 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOLDRIDGE | ||||||||
| FirstName: | ABBY | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8711 CHIMNEY HILL PL | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468043414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604832100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3320 N CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604832100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 22004146A | IN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 000000506517 | 01 | IN | ANTHEM | OTHER |