Provider Demographics
NPI:1104035906
Name:WAHLBERG, REGAN MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REGAN
Middle Name:MARIE
Last Name:WAHLBERG
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 E ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2404
Mailing Address - Country:US
Mailing Address - Phone:602-538-5123
Mailing Address - Fax:
Practice Address - Street 1:1817 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2133
Practice Address - Country:US
Practice Address - Phone:602-538-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4879235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist