Basic Information
| Provider Information | |||||||||
| NPI: | 1750467536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYCOFF | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED.,CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 COLONIAL AVE SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240153204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403430165 | ||||||||
| FaxNumber: | 5403454664 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 COLONIAL AVE SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240153204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403430165 | ||||||||
| FaxNumber: | 5403454664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| 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 | 2202001523 | VA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 195185 | 01 | VA | ANTHEM | OTHER | 0007790506 | 01 | VA | AETNA | OTHER | 240052 | 01 | VA | MAMSI | OTHER |