Provider Demographics
NPI:1619021847
Name:WENNERHOLM, LAURIE JEAN (MA, CCC-SLP, BRS-S)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:JEAN
Last Name:WENNERHOLM
Suffix:
Gender:F
Credentials:MA, CCC-SLP, BRS-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3613 212TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2048
Mailing Address - Country:US
Mailing Address - Phone:718-352-0429
Mailing Address - Fax:
Practice Address - Street 1:2 LONGVIEW AVE FL 6
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-5000
Practice Address - Country:US
Practice Address - Phone:914-849-7586
Practice Address - Fax:914-849-7958
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011025-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist