Provider Demographics
NPI:1164035630
Name:PENNEBAKER, MADELINE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:PENNEBAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BUCKINGHAM ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4313
Mailing Address - Country:US
Mailing Address - Phone:713-498-6194
Mailing Address - Fax:
Practice Address - Street 1:16 BUCKINGHAM ST APT 2
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-4313
Practice Address - Country:US
Practice Address - Phone:617-475-0462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77697235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist