Provider Demographics
NPI:1669915815
Name:WADA, CARRIE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:WADA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 S LEXINGTON PL
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-4935
Mailing Address - Country:US
Mailing Address - Phone:714-586-7475
Mailing Address - Fax:
Practice Address - Street 1:17842 IRVINE BLVD STE 118
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3243
Practice Address - Country:US
Practice Address - Phone:949-903-8229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25390235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA25390OtherSLPAB