Provider Demographics
NPI:1477267110
Name:WAHBA, MALLORY NICOLE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:NICOLE
Last Name:WAHBA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 BLYTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-6309
Mailing Address - Country:US
Mailing Address - Phone:734-626-2838
Mailing Address - Fax:
Practice Address - Street 1:1010 BLYTHWOOD DR
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SC
Practice Address - Zip Code:29673-6309
Practice Address - Country:US
Practice Address - Phone:734-626-2838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8112235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist