Provider Demographics
NPI:1114202017
Name:WOHLFORTH, BETTINA (AUD)
Entity Type:Individual
Prefix:
First Name:BETTINA
Middle Name:
Last Name:WOHLFORTH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MELROSE AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6277
Mailing Address - Country:US
Mailing Address - Phone:203-661-7879
Mailing Address - Fax:
Practice Address - Street 1:100 MELROSE AVE STE 108
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6277
Practice Address - Country:US
Practice Address - Phone:203-661-7879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT171231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist