Provider Demographics
NPI:1083493381
Name:PENKETHMAN, PHYLLIS R (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:R
Last Name:PENKETHMAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:M
Other - Last Name:RINEHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-0213
Mailing Address - Country:US
Mailing Address - Phone:908-773-0752
Mailing Address - Fax:
Practice Address - Street 1:3349 HWY 138
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9671
Practice Address - Country:US
Practice Address - Phone:732-280-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJYS001121235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist