Provider Demographics
NPI:1073296489
Name:WAIDELICH, ABBY GRACE
Entity Type:Individual
Prefix:MRS
First Name:ABBY
Middle Name:GRACE
Last Name:WAIDELICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 NOLAN PKWY
Mailing Address - Street 2:
Mailing Address - City:ARCHBOLD
Mailing Address - State:OH
Mailing Address - Zip Code:43502-8404
Mailing Address - Country:US
Mailing Address - Phone:567-444-4800
Mailing Address - Fax:
Practice Address - Street 1:6950 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-9030
Practice Address - Country:US
Practice Address - Phone:567-444-4825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.20232335-SP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist