Healthcare Provider Details

I. General information

NPI: 1265485726
Provider Name (Legal Business Name): RANDY EARL WANTTAJA M.A., C.C.C.-S.L.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 PROVIDENCE RD SUITE 80
VIRGINIA BEACH VA
23464-4128
US

IV. Provider business mailing address

5301 PROVIDENCE RD SUITE 80
VIRGINIA BEACH VA
23464-4128
US

V. Phone/Fax

Practice location:
  • Phone: 757-467-1900
  • Fax: 757-467-7900
Mailing address:
  • Phone: 757-467-1900
  • Fax: 757-467-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202004535
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: