Provider Demographics
NPI:1366860546
Name:WAKE PEDIATRIC SPEECH THERAPY
Entity Type:Organization
Organization Name:WAKE PEDIATRIC SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:919-593-8104
Mailing Address - Street 1:1157 EXECUTIVE CIR STE B1
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-4579
Mailing Address - Country:US
Mailing Address - Phone:919-593-8104
Mailing Address - Fax:919-882-8110
Practice Address - Street 1:1157 EXECUTIVE CIR STE B1
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4579
Practice Address - Country:US
Practice Address - Phone:919-593-8104
Practice Address - Fax:919-882-8110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5439261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7413900Medicaid