Provider Demographics
NPI:1962193169
Name:JOSEPH, WOLLY JEFFERSON
Entity type:Individual
Prefix:MR
First Name:WOLLY
Middle Name:JEFFERSON
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 BEACON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-4213
Mailing Address - Country:US
Mailing Address - Phone:508-897-9171
Mailing Address - Fax:
Practice Address - Street 1:1224 BEACON ST APT 3
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-4213
Practice Address - Country:US
Practice Address - Phone:508-897-9171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN29002063A2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant