Provider Demographics
NPI:1629834627
Name:WYDICK, ANDREA RENAE (SLP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:RENAE
Last Name:WYDICK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:RENAE
Other - Last Name:MASERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NIMS
Mailing Address - Street 1:22507 S 2325 RD
Mailing Address - Street 2:
Mailing Address - City:MILO
Mailing Address - State:MO
Mailing Address - Zip Code:64767-7643
Mailing Address - Country:US
Mailing Address - Phone:417-684-0105
Mailing Address - Fax:
Practice Address - Street 1:22507 S 2325 RD
Practice Address - Street 2:
Practice Address - City:MILO
Practice Address - State:MO
Practice Address - Zip Code:64767-7643
Practice Address - Country:US
Practice Address - Phone:417-684-0105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013033373235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist