Provider Demographics
NPI:1730306028
Name:WYNN DBA SPEECH EFX, BEULAH ISRAEL (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BEULAH
Middle Name:ISRAEL
Last Name:WYNN DBA SPEECH EFX
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 1:6322 25TH ST S
Mailing Address - Street 2:APT 142
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-5399
Mailing Address - Country:US
Mailing Address - Phone:727-866-7603
Mailing Address - Fax:
Practice Address - Street 1:6322 25TH ST S
Practice Address - Street 2:APT 142
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-5399
Practice Address - Country:US
Practice Address - Phone:727-866-7603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6658235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12046539OtherASHA SLP LICENSE
FL887698300Medicaid
FLSA6658OtherDOH SLP LICENSE