Provider Demographics
NPI:1346569514
Name:WAIDELICH, JULIE EGGLESTON (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:EGGLESTON
Last Name:WAIDELICH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:JULIE
Other - Middle Name:KAY
Other - Last Name:EGGLESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:4103 ASCENDANT DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-5302
Mailing Address - Country:US
Mailing Address - Phone:719-322-5552
Mailing Address - Fax:
Practice Address - Street 1:4103 ASCENDANT DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-5302
Practice Address - Country:US
Practice Address - Phone:719-322-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12019320235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36935271Medicare UPIN