Provider Demographics
NPI:1831404664
Name:OMTA, ANN M (MA, CCC-SLP, L)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:OMTA
Suffix:
Gender:F
Credentials:MA, CCC-SLP, L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ROZA VIEW RD
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-9735
Mailing Address - Country:US
Mailing Address - Phone:509-837-8665
Mailing Address - Fax:
Practice Address - Street 1:100 ROZA VIEW RD
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-9735
Practice Address - Country:US
Practice Address - Phone:509-837-8665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 00003290235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist