Provider Demographics
NPI:1992803423
Name:WAKEFIELD, TESSIE S (MA CCCSLP)
Entity type:Individual
Prefix:MRS
First Name:TESSIE
Middle Name:S
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:TESSIE
Other - Middle Name:J
Other - Last Name:SAKELLAKIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCCSLP
Mailing Address - Street 1:1159 HUNTERS RIDGE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44904
Mailing Address - Country:US
Mailing Address - Phone:419-884-0811
Mailing Address - Fax:
Practice Address - Street 1:270 STERKEL BLVD
Practice Address - Street 2:THE REHAB CENTER
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2207
Practice Address - Country:US
Practice Address - Phone:419-756-1133
Practice Address - Fax:419-756-6544
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP3045235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000125366OtherANTHEM
3407897499218OtherANTHEM