Provider Demographics
NPI:1598214389
Name:WAYNE STATE UNIVERSITY SPEECH AND LANGUAGE CENTER
Entity Type:Organization
Organization Name:WAYNE STATE UNIVERSITY SPEECH AND LANGUAGE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL INSTRUCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIENING
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:313-577-3339
Mailing Address - Street 1:60 FARNSWORTH
Mailing Address - Street 2:ROOM 207
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-577-3339
Mailing Address - Fax:
Practice Address - Street 1:60 FARNSWORTH ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-4060
Practice Address - Country:US
Practice Address - Phone:313-577-3339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001401261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center