Provider Demographics
NPI:1669652749
Name:WELLIK, DANIELLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:WELLIK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 770495
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-0495
Mailing Address - Country:US
Mailing Address - Phone:907-854-6935
Mailing Address - Fax:
Practice Address - Street 1:18008 KAMKOFF AVE
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-9323
Practice Address - Country:US
Practice Address - Phone:907-854-6935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP2148235Z00000X
AK399235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist