Provider Demographics
NPI:1700190949
Name:WAND, VICKIE LYNN (MS-CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:VICKIE
Middle Name:LYNN
Last Name:WAND
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 1:1359 E SAINT LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-3409
Mailing Address - Country:US
Mailing Address - Phone:417-523-0000
Mailing Address - Fax:
Practice Address - Street 1:2205 W KEARNEY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2028
Practice Address - Country:US
Practice Address - Phone:417-523-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010025346235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODIAMOND1Medicaid