Healthcare Provider Details

I. General information

NPI: 1003632043
Provider Name (Legal Business Name): RACHEL CHARLOTTE WALDHOLZ CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 W MILHAM AVE
PORTAGE MI
49024-1232
US

IV. Provider business mailing address

1908 W MILHAM AVE
PORTAGE MI
49024-1232
US

V. Phone/Fax

Practice location:
  • Phone: 269-459-6212
  • Fax: 269-585-6068
Mailing address:
  • Phone: 269-459-6212
  • Fax: 269-585-6068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101009034
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: