Provider Demographics
NPI:1508555350
Name:MANN, RANDALL WADE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:WADE
Last Name:MANN
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 HORIZON AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9728
Mailing Address - Country:US
Mailing Address - Phone:307-752-2175
Mailing Address - Fax:
Practice Address - Street 1:3785 HORIZON AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9728
Practice Address - Country:US
Practice Address - Phone:307-752-2175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-967235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist