Provider Demographics
NPI:1598313892
Name:WOLLWEBER, ALEXANDRA NICOLE (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:WOLLWEBER
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 1:166 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:N MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-3017
Mailing Address - Country:US
Mailing Address - Phone:347-873-7255
Mailing Address - Fax:
Practice Address - Street 1:71 CLINTON RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4742
Practice Address - Country:US
Practice Address - Phone:516-396-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029041246Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology