Provider Demographics
NPI:1861553661
Name:WALICKE, ALAN PAUL (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:PAUL
Last Name:WALICKE
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 BEGONIA PL
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-5029
Mailing Address - Country:US
Mailing Address - Phone:928-541-9508
Mailing Address - Fax:
Practice Address - Street 1:1903 BEGONIA PL
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-5029
Practice Address - Country:US
Practice Address - Phone:928-541-9508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0060235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist