Healthcare Provider Details

I. General information

NPI: 1619204765
Provider Name (Legal Business Name): WENDY DEICAS SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 JEFFERSON AVENUE GRANT COUNTY BOARD OF EDUCATION
PETERSBURG WV
26847
US

IV. Provider business mailing address

204 JEFFERSON AVENUE GRANT COUNTY BOARD OF EDUCATION
PETERSBURG WV
26847
US

V. Phone/Fax

Practice location:
  • Phone: 304-267-3595
  • Fax: 304-267-3599
Mailing address:
  • Phone: 304-267-3595
  • Fax: 304-267-3599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9440
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: