Healthcare Provider Details

I. General information

NPI: 1952219099
Provider Name (Legal Business Name): KATHLEEN ROSELLA WAHL SLP-CCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 E MAIN ST
MANCHESTER MI
48158-9588
US

IV. Provider business mailing address

19603 BETHEL CHURCH RD
MANCHESTER MI
48158-8733
US

V. Phone/Fax

Practice location:
  • Phone: 734-428-7442
  • Fax:
Mailing address:
  • Phone: 517-745-1198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101009275
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: