Provider Demographics
NPI:1689051880
Name:BACH, WANDA (CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:
Last Name:BACH
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13415 HIGHWAY 30 E
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-7888
Mailing Address - Country:US
Mailing Address - Phone:606-666-8488
Mailing Address - Fax:
Practice Address - Street 1:13415 HIGHWAY 30 E
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-7888
Practice Address - Country:US
Practice Address - Phone:606-666-8488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0962235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist