Provider Demographics
NPI:1609010529
Name:BLAKE, WENDY (SLP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:133 GOLD MILL PL
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-4025
Mailing Address - Country:US
Mailing Address - Phone:703-400-5518
Mailing Address - Fax:
Practice Address - Street 1:133 GOLD MILL PL
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-4025
Practice Address - Country:US
Practice Address - Phone:703-400-5518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006297235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist