Provider Demographics
NPI:1306125356
Name:WACKS, MARLENE
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:WACKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 EUSTON RD
Mailing Address - Street 2:#109
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-4143
Mailing Address - Country:US
Mailing Address - Phone:401-374-5625
Mailing Address - Fax:
Practice Address - Street 1:484 MAIN ST
Practice Address - Street 2:EASTER SEALS MASSACHUSETTS
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1893
Practice Address - Country:US
Practice Address - Phone:800-244-2756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8302235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist