Provider Demographics
NPI:1265485726
Name:WANTTAJA, RANDY EARL (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:EARL
Last Name:WANTTAJA
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 PROVIDENCE RD
Mailing Address - Street 2:SUITE 80
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4128
Mailing Address - Country:US
Mailing Address - Phone:757-467-1900
Mailing Address - Fax:757-467-7900
Practice Address - Street 1:5301 PROVIDENCE RD
Practice Address - Street 2:SUITE 80
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4128
Practice Address - Country:US
Practice Address - Phone:757-467-1900
Practice Address - Fax:757-467-7900
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004535235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist