Provider Demographics
NPI:1629474499
Name:WODICKA, JANE K (MA, CCC-SLP, TSHH)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:K
Last Name:WODICKA
Suffix:
Gender:F
Credentials:MA, CCC-SLP, TSHH
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:22 PROVOST LN
Mailing Address - Street 2:
Mailing Address - City:GREAT RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11739-3017
Mailing Address - Country:US
Mailing Address - Phone:631-921-2463
Mailing Address - Fax:631-859-0582
Practice Address - Street 1:22 PROVOST LN
Practice Address - Street 2:
Practice Address - City:GREAT RIVER
Practice Address - State:NY
Practice Address - Zip Code:11739-3017
Practice Address - Country:US
Practice Address - Phone:631-921-2463
Practice Address - Fax:631-859-0582
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011832-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist