Provider Demographics
NPI:1831274802
Name:WACKER-MUNDY, ROBERTA LYNN (PHD)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:LYNN
Last Name:WACKER-MUNDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MISS
Other - First Name:ROBERT
Other - Middle Name:LYNN
Other - Last Name:WACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:101 BROAD STREET
Mailing Address - Street 2:PLATTSBURGH STATE UNIV OF NEW YORK SPEECH AND HEARING
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2681
Mailing Address - Country:US
Mailing Address - Phone:518-564-2170
Mailing Address - Fax:518-564-5110
Practice Address - Street 1:101 BROAD STREET
Practice Address - Street 2:224 SIBLEY HALL
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2681
Practice Address - Country:US
Practice Address - Phone:518-564-2170
Practice Address - Fax:518-564-5110
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4527235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist