Provider Demographics
NPI:1740427400
Name:WANNEMACHER THERAPY SERVICES, P.C.
Entity Type:Organization
Organization Name:WANNEMACHER THERAPY SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WANNEMACHER
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP/L
Authorized Official - Phone:815-260-6596
Mailing Address - Street 1:1254 PULLMAN RD
Mailing Address - Street 2:APT. 304
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-4183
Mailing Address - Country:US
Mailing Address - Phone:815-260-6596
Mailing Address - Fax:206-462-1510
Practice Address - Street 1:1254 PULLMAN RD
Practice Address - Street 2:APT. 304
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-4183
Practice Address - Country:US
Practice Address - Phone:815-260-6596
Practice Address - Fax:206-462-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005457235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL320761490001Medicaid