Provider Demographics
NPI:1093968893
Name:WOLLENWEBER, ROBERT W (MS CCA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:WOLLENWEBER
Suffix:
Gender:M
Credentials:MS CCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 S 700 E
Mailing Address - Street 2:STE 10
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2180
Mailing Address - Country:US
Mailing Address - Phone:801-268-4141
Mailing Address - Fax:
Practice Address - Street 1:196 E 2000 N
Practice Address - Street 2:STE 100A
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9335
Practice Address - Country:US
Practice Address - Phone:435-882-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT110181-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist