Provider Demographics
NPI:1902059637
Name:VAN WIE, BRENDA M (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:M
Last Name:VAN WIE
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 1:2142 STATE ROUTE 4
Mailing Address - Street 2:
Mailing Address - City:FORT EDWARD
Mailing Address - State:NY
Mailing Address - Zip Code:12828-3409
Mailing Address - Country:US
Mailing Address - Phone:518-747-0843
Mailing Address - Fax:
Practice Address - Street 1:2142 STATE ROUTE 4
Practice Address - Street 2:
Practice Address - City:FORT EDWARD
Practice Address - State:NY
Practice Address - Zip Code:12828-3409
Practice Address - Country:US
Practice Address - Phone:518-747-0843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-26
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006161-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01060966OtherAMERICAN SPEECH AND HEARING ASSOCIATION ASHA
NY006161-1OtherNEW YORK STATE LICENSE IN SPEECH PATHOLOGY