Basic Information
Provider Information | |||||||||
NPI: | 1992803423 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WAKEFIELD | ||||||||
FirstName: | TESSIE | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA CCCSLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SAKELLAKIS | ||||||||
OtherFirstName: | TESSIE | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MA CCCSLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1159 HUNTERS RIDGE | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | OH | ||||||||
PostalCode: | 44904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198840811 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 270 STERKEL BLVD | ||||||||
Address2: | THE REHAB CENTER | ||||||||
City: | MANSFIELD | ||||||||
State: | OH | ||||||||
PostalCode: | 449072207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197561133 | ||||||||
FaxNumber: | 4197566544 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP3045 | OH | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 000000125366 | 01 |   | ANTHEM | OTHER | 3407897499218 | 01 |   | ANTHEM | OTHER |