Basic Information
| Provider Information | |||||||||
| NPI: | 1386841997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAKELAND | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | MED CCC SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 771 E 800 N | ||||||||
| Address2: | |||||||||
| City: | PLEASANT GROVE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840621957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017965385 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 ALPINE AVE | ||||||||
| Address2: | |||||||||
| City: | PLEASANT GROVE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840623511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017853568 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 5319199-4102 | UT | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 870574059031 | 05 | UT | MEDICAID |