Provider Demographics
NPI:1417262262
Name:WONDRAK, LEAH (SLP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:WONDRAK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 N LINCOLN ST STE A
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-3238
Mailing Address - Country:US
Mailing Address - Phone:707-366-5246
Mailing Address - Fax:
Practice Address - Street 1:255 N LINCOLN ST STE A
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:CA
Practice Address - Zip Code:95620-3238
Practice Address - Country:US
Practice Address - Phone:707-366-5247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.9817235Z00000X
CASP28956235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0028740Medicaid
OH0028740Medicaid