Healthcare Provider Details

I. General information

NPI: 1184291882
Provider Name (Legal Business Name): KERRY A WADE M.S.CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. KERRY ANN WILTZ

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 MAIN ST
PARKS LA
70582-6639
US

IV. Provider business mailing address

1122 PAPIT GUIDRY RD
SAINT MARTINVILLE LA
70582-6211
US

V. Phone/Fax

Practice location:
  • Phone: 337-909-2939
  • Fax:
Mailing address:
  • Phone: 337-280-2066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3081
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: