Provider Demographics
NPI:1043455249
Name:WANTUCH, DEBRA (AUD, FAAA, CCC-A)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:WANTUCH
Suffix:
Gender:F
Credentials:AUD, FAAA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47-48 196 STREET
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358
Mailing Address - Country:US
Mailing Address - Phone:718-357-4682
Mailing Address - Fax:
Practice Address - Street 1:47-48 196 STREET
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358
Practice Address - Country:US
Practice Address - Phone:718-357-4682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000880-1231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist