Provider Demographics
NPI:1760495634
Name:WISEHEART, REBECCA MAULDEN (MA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:MAULDEN
Last Name:WISEHEART
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 NW 13TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-4095
Mailing Address - Country:US
Mailing Address - Phone:352-514-8808
Mailing Address - Fax:352-374-9960
Practice Address - Street 1:1410 NW 13TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4095
Practice Address - Country:US
Practice Address - Phone:352-514-8808
Practice Address - Fax:352-374-9960
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3158235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8892491Medicaid