Provider Demographics
NPI:1689727174
Name:WOOTEN, RITA P (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:RITA
Middle Name:P
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CIELO MONTANA
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-9547
Mailing Address - Country:US
Mailing Address - Phone:505-463-6518
Mailing Address - Fax:
Practice Address - Street 1:906 JUAN PEREA RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7778
Practice Address - Country:US
Practice Address - Phone:505-866-7632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118992235Z00000X
NM2026235Z00000X
CO0001004235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR8011Medicaid