Provider Demographics
NPI:1316405129
Name:WALLAK, RAECHAL LYNN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RAECHAL
Middle Name:LYNN
Last Name:WALLAK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:RAECHAL
Other - Middle Name:LYNN
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:1400 BIRCH DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120
Mailing Address - Country:US
Mailing Address - Phone:716-812-5750
Mailing Address - Fax:
Practice Address - Street 1:150 STAHL ROAD
Practice Address - Street 2:
Practice Address - City:GETZVILLE
Practice Address - State:NY
Practice Address - Zip Code:14068-1231
Practice Address - Country:US
Practice Address - Phone:716-629-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
NY030181235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06511893Medicaid