Provider Demographics
NPI:1285985986
Name:SPRAGUE, WENDY EILEEN (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:EILEEN
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:MED, 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:HC 66 BOX 235
Mailing Address - Street 2:
Mailing Address - City:MOYERS
Mailing Address - State:OK
Mailing Address - Zip Code:74557-9700
Mailing Address - Country:US
Mailing Address - Phone:817-999-1435
Mailing Address - Fax:
Practice Address - Street 1:402 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2087
Practice Address - Country:US
Practice Address - Phone:580-298-9818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100811235Z00000X
OK3981235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist