Provider Demographics
NPI:1710398391
Name:WILLEKE, CONNIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:WILLEKE
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 1:1135 SANDUSKY PL
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-3146
Mailing Address - Country:US
Mailing Address - Phone:419-872-0456
Mailing Address - Fax:
Practice Address - Street 1:18505 TONTOGANY CREEK ROAD
Practice Address - Street 2:
Practice Address - City:TONTOGANY
Practice Address - State:OH
Practice Address - Zip Code:43565
Practice Address - Country:US
Practice Address - Phone:419-823-4381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP 7301235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist