Provider Demographics
NPI:1952782443
Name:WAX, CHANA (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CHANA
Middle Name:
Last Name:WAX
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3327 S TWYCKENHAM DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2153
Mailing Address - Country:US
Mailing Address - Phone:443-608-0169
Mailing Address - Fax:
Practice Address - Street 1:113 LINCOLNWAY E
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2016
Practice Address - Country:US
Practice Address - Phone:443-608-0169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006120A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist