MEDICARE: MR. RANDY EARL WANTTAJA M.A., C.C.C.-S.L.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	2202004535	VA

General Provider Information

NPI Number	:	1265485726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDY EARL WANTTAJA M.A., C.C.C.-S.L.P.

Provider Business Mailing Address
First Line	:	5301 PROVIDENCE RD
Second Line	:	SUITE 80
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-4128
Country	:	US
Telephone Number	:	757-467-1900
Fax Number	:	757-467-7900

Provider Business Practice Location Address
First Line	:	5301 PROVIDENCE RD
Second Line	:	SUITE 80
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-4128
Country	:	US
Telephone Number	:	757-467-1900
Fax Number	:	757-467-7900

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	07/08/2007

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