Basic Information
| Provider Information | |||||||||
| NPI: | 1912238940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENGELL | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA CCC - SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ABRAHAM | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA CCC - SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 484 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060010484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606774048 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 51 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060013821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604042461 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2010 | ||||||||
| LastUpdateDate: | 05/29/2012 | ||||||||
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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 | 004128 | CT | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.