Basic Information
Provider Information | |||||||||
NPI: | 1316405129 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALLAK | ||||||||
FirstName: | RAECHAL | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S. CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MACK | ||||||||
OtherFirstName: | RAECHAL | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.S. CCC-SLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1400 BIRCH DRIVE | ||||||||
Address2: |   | ||||||||
City: | NORTH TONAWANDA | ||||||||
State: | NY | ||||||||
PostalCode: | 14120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168125750 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 150 STAHL ROAD | ||||||||
Address2: |   | ||||||||
City: | GETZVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 140681231 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166293400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/11/2019 | ||||||||
LastUpdateDate: | 11/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X |   | NY | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 030181 | NY | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 06511893 | 05 | NY |   | MEDICAID |