Provider Demographics
NPI:1912238940
Name:WENGELL, COURTNEY A (MA CCC - SLP)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:A
Last Name:WENGELL
Suffix:
Gender:F
Credentials:MA CCC - SLP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:L
Other - Last Name:ABRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC - SLP
Mailing Address - Street 1:PO BOX 484
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-0484
Mailing Address - Country:US
Mailing Address - Phone:860-677-4048
Mailing Address - Fax:
Practice Address - Street 1:51 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3821
Practice Address - Country:US
Practice Address - Phone:860-404-2461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004128235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist