Basic Information
| Provider Information | |||||||||
| NPI: | 1841667268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | ALLYSON | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | ALLYSON | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2600 COMPASS RD | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600268001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777873422 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 515 CHESAPEAKE DR | ||||||||
| Address2: | |||||||||
| City: | TARPON SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346892515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7279344629 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2015 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SZ7251 | FL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SA14786 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 015656900 | 05 | FL | MEDICAID |