Provider Demographics
NPI:1609286517
Name:WOLANIN, STACIE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:WOLANIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:MERTOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5544 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-580-3976
Mailing Address - Fax:
Practice Address - Street 1:5544 MAIN ST.
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-580-3976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY024630235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program