Provider Demographics
NPI:1538317839
Name:MARCHELLETTA, KATHERINE MARIE-WAGNER (AUD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE-WAGNER
Last Name:MARCHELLETTA
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:MARIE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:K-8
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-1083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000523231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter