Elyse Wahlquist Van Wagenen, MA CCC SLP

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

SA17587 Issued in FL

Practice address

11287 NW State Road 20
Bristol, FL 32321-3414

Phone

(850) 694-4420

NPI assigned

May 23, 2019

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Arts

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1558569600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1733097600000",
    "number": "1346807476",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11287 NW STATE ROAD 20",
            "city": "BRISTOL",
            "state": "FL",
            "postal_code": "323213414",
            "telephone_number": "850-694-4420"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11287 NW STATE ROAD 20",
            "city": "BRISTOL",
            "state": "FL",
            "postal_code": "323213414",
            "telephone_number": "850-694-4420"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2930 Capital Medical Blvd",
            "address_purpose": "LOCATION",
            "city": "Tallahassee",
            "state": "FL",
            "postal_code": "323084408",
            "country_code": "US",
            "telephone_number": "850-694-4420",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2600 Douglass Rd SE",
            "address_purpose": "LOCATION",
            "city": "Washington, DC",
            "state": "DC",
            "postal_code": "20020",
            "country_code": "US",
            "telephone_number": "850-694-4429",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "VAN WAGENEN",
        "first_name": "ELYSE",
        "middle_name": "WAHLQUIST",
        "credential": "MA CCC SLP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-05-23",
        "last_updated": "2024-12-02",
        "certification_date": "2024-12-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "DC",
            "license": "SLPCF000042",
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "FL",
            "license": "SA17587",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Speech-Language Pathologist in Bristol, FL
• Providers in Bristol, FL by specialty
• Speech-Language Pathologist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.