Provider Demographics
NPI:1154738631
Name:WYNNE, HEATHER (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WYNNE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 EDISON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-1237
Mailing Address - Country:US
Mailing Address - Phone:215-856-5700
Mailing Address - Fax:
Practice Address - Street 1:650 EDISON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-1237
Practice Address - Country:US
Practice Address - Phone:215-856-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL011464235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist