Provider Demographics
NPI:1346714383
Name:WAHLQUIST, HAMMADAH TALIB
Entity Type:Individual
Prefix:
First Name:HAMMADAH
Middle Name:TALIB
Last Name:WAHLQUIST
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 1:13005 NW JOE CHASON CIR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321-3144
Mailing Address - Country:US
Mailing Address - Phone:850-570-7178
Mailing Address - Fax:
Practice Address - Street 1:11288 NW STATE ROAD 20
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-3481
Practice Address - Country:US
Practice Address - Phone:850-570-7178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-13
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
FLSI38022355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant