Healthcare Provider Details

I. General information

NPI: 1730306028
Provider Name (Legal Business Name): BEULAH ISRAEL WYNN DBA SPEECH EFX M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6322 25TH ST S APT 142
SAINT PETERSBURG FL
33712-5399
US

IV. Provider business mailing address

6322 25TH ST S APT 142
SAINT PETERSBURG FL
33712-5399
US

V. Phone/Fax

Practice location:
  • Phone: 727-866-7603
  • Fax:
Mailing address:
  • Phone: 727-866-7603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA6658
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: