Provider Demographics
NPI:1598378754
Name:WAN, TREISHA (SLP)
Entity Type:Individual
Prefix:
First Name:TREISHA
Middle Name:
Last Name:WAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8803 W VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-3101
Mailing Address - Country:US
Mailing Address - Phone:847-913-5288
Mailing Address - Fax:
Practice Address - Street 1:8803 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-3101
Practice Address - Country:US
Practice Address - Phone:623-907-5260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP12583235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist