Provider Demographics
NPI:1164066585
Name:FUDGE, DEIRDRE COLLEEN (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:COLLEEN
Last Name:FUDGE
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3341 NW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-3827
Mailing Address - Country:US
Mailing Address - Phone:405-314-7408
Mailing Address - Fax:
Practice Address - Street 1:3341 NW 19TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-3827
Practice Address - Country:US
Practice Address - Phone:405-314-7408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2681235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty