Provider Demographics
NPI:1679612758
Name:KEELER, WENDY ALLISON (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:ALLISON
Last Name:KEELER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MS
Other - First Name:WENDY
Other - Middle Name:ALLISON
Other - Last Name:HOLMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:223 HERITAGE MILL DR.
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-1543
Mailing Address - Country:US
Mailing Address - Phone:407-310-6052
Mailing Address - Fax:
Practice Address - Street 1:223 HERITAGE MILL DR.
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1543
Practice Address - Country:US
Practice Address - Phone:407-310-6052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6480235Z00000X
AL3416235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12054899OtherASHA NUMBER
FLSA 6480OtherSTATE LICENSE
FL686276496Medicaid
FL886822100Medicaid
AL3416OtherALABAMA STATE LICENSE