Provider Demographics
NPI:1346807476
Name:WAHLQUIST, ELYSE NINA
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:NINA
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 1:2600 DOUGLASS RD SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON, DC
Mailing Address - State:DC
Mailing Address - Zip Code:20020
Mailing Address - Country:US
Mailing Address - Phone:850-694-4429
Mailing Address - Fax:
Practice Address - Street 1:2930 CAPITAL MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4408
Practice Address - Country:US
Practice Address - Phone:850-694-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCSLPCF000042235Z00000X
FLSA17587235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist