MEDICARE: RAEANNE WETZEL M.A. CCC-SLP

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

General Provider Information

NPI Number	:	1477788503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAEANNE WETZEL M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	3728 N MARSHFIELD AVE
Second Line	:	UNIT 1
City	:	CHICAGO
State	:	IL
Zip	:	60613-3622
Country	:	US
Telephone Number	:	330-718-2755
Fax Number	:

Provider Business Practice Location Address
First Line	:	3728 N MARSHFIELD AVE
Second Line	:	UNIT 1
City	:	CHICAGO
State	:	IL
Zip	:	60613-3622
Country	:	US
Telephone Number	:	330-718-2755
Fax Number	:

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

Provider Enumeration Date	:	05/19/2009
Last Update Date	:	10/12/2012

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