Provider Demographics
NPI:1700438439
Name:JOHN, ABIGAIL WADE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ABIGAIL
Middle Name:WADE
Last Name:JOHN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:9606 TIERRA GRANDE ST STE 107
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-6501
Mailing Address - Country:US
Mailing Address - Phone:858-695-9415
Mailing Address - Fax:858-695-9412
Practice Address - Street 1:9606 TIERRA GRANDE ST STE 107
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-6501
Practice Address - Country:US
Practice Address - Phone:858-695-9415
Practice Address - Fax:858-695-9412
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28653235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist