Provider Demographics
NPI:1760888218
Name:WOOTEN, ALICIA ELLEN (AUD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:ELLEN
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:DR
Other - First Name:ALICIA
Other - Middle Name:ELLEN
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AU,D
Mailing Address - Street 1:620 WALTON DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1935
Mailing Address - Country:US
Mailing Address - Phone:573-756-0500
Mailing Address - Fax:573-756-0505
Practice Address - Street 1:620 WALTON DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1935
Practice Address - Country:US
Practice Address - Phone:573-756-0500
Practice Address - Fax:573-756-0505
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014035188231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist