Provider Demographics
NPI:1558587105
Name:WOLVERTON, ANN L (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:L
Last Name:WOLVERTON
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 FAIRVIEW AVE N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5421
Mailing Address - Country:US
Mailing Address - Phone:651-647-1106
Mailing Address - Fax:
Practice Address - Street 1:1946 FAIRVIEW AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-5421
Practice Address - Country:US
Practice Address - Phone:651-647-1106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6068235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist