Provider Demographics
NPI:1972617264
Name:WANCA, REBECCA (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:WANCA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 43RD STREET BLVD E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-5447
Mailing Address - Country:US
Mailing Address - Phone:941-746-1317
Mailing Address - Fax:
Practice Address - Street 1:212 43RD STREET BLVD E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-5447
Practice Address - Country:US
Practice Address - Phone:941-746-1317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5143235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8846022Medicaid