Provider Demographics
NPI:1386841997
Name:WAKELAND, SUE ANNE (MED CCC SLP)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:ANNE
Last Name:WAKELAND
Suffix:
Gender:F
Credentials:MED CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 E 800 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-1957
Mailing Address - Country:US
Mailing Address - Phone:801-796-5385
Mailing Address - Fax:
Practice Address - Street 1:25 ALPINE AVE
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3511
Practice Address - Country:US
Practice Address - Phone:801-785-3568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5319199-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870574059031Medicaid