Healthcare Provider Details

I. General information

NPI: 1669888962
Provider Name (Legal Business Name): HEIDI WACKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9047 W GREENFIELD AVE
WEST ALLIS WI
53214-2808
US

IV. Provider business mailing address

9047 W GREENFIELD AVE
WEST ALLIS WI
53214-2808
US

V. Phone/Fax

Practice location:
  • Phone: 414-453-9290
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3976
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: