Provider Demographics
NPI:1639131097
Name:GRANT, WENDY (MA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 FOREST HILL BLVD
Mailing Address - Street 2:STE 205
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5878
Mailing Address - Country:US
Mailing Address - Phone:561-649-4006
Mailing Address - Fax:561-969-6621
Practice Address - Street 1:3540 FOREST HILL BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-5878
Practice Address - Country:US
Practice Address - Phone:561-649-4006
Practice Address - Fax:561-969-6621
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1282235Z00000X
237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS0886OtherBCBS
FL882144500Medicaid
FLS0886Medicare ID - Type Unspecified