Provider Demographics
NPI:1083139497
Name:WANGSGARD, MITCH SMEDING
Entity Type:Individual
Prefix:MR
First Name:MITCH
Middle Name:SMEDING
Last Name:WANGSGARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 W HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1618
Mailing Address - Country:US
Mailing Address - Phone:801-603-0065
Mailing Address - Fax:618-724-4496
Practice Address - Street 1:1415 W HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1618
Practice Address - Country:US
Practice Address - Phone:618-624-4471
Practice Address - Fax:618-624-4496
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017025273231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty