Provider Demographics
NPI:1346465523
Name:WAYT, TERRY
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:WAYT
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 1:28764 ROAD P
Mailing Address - Street 2:
Mailing Address - City:DOLORES
Mailing Address - State:CO
Mailing Address - Zip Code:81323-9379
Mailing Address - Country:US
Mailing Address - Phone:970-882-7484
Mailing Address - Fax:
Practice Address - Street 1:28764 ROAD P
Practice Address - Street 2:
Practice Address - City:DOLORES
Practice Address - State:CO
Practice Address - Zip Code:81323-9379
Practice Address - Country:US
Practice Address - Phone:970-882-7484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0193931235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO73475815Medicaid