Provider Demographics
NPI:1689942211
Name:BADALATI WELTEN, JOHANNA CORNELIA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:CORNELIA
Last Name:BADALATI WELTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BANNER LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8844
Mailing Address - Country:US
Mailing Address - Phone:386-597-7420
Mailing Address - Fax:
Practice Address - Street 1:393 PALM COAST PKWY SW UNIT 3
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4774
Practice Address - Country:US
Practice Address - Phone:386-793-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-10
Last Update Date:2011-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ5683235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist