Provider Demographics
NPI:1053667089
Name:PETHAN, MADELEINE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MADELEINE
Middle Name:
Last Name:PETHAN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MRS
Other - First Name:MADELEINE
Other - Middle Name:
Other - Last Name:HAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:
Practice Address - Street 1:6035 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3256
Practice Address - Country:US
Practice Address - Phone:704-295-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET001789235Z00000X
NC12104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1053667089Medicaid
SC1260932OtherWELLCARE
SCSAN138Medicaid
NC19KQ3OtherBCBSNC
4808956OtherAETNA
4808956OtherAETNA