Provider Demographics
NPI:1215553177
Name:PANKOW, LAUREN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:PANKOW
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17861 SADDLE RD
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33982-5148
Mailing Address - Country:US
Mailing Address - Phone:239-295-4614
Mailing Address - Fax:
Practice Address - Street 1:22900 LYDEN DR
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-7044
Practice Address - Country:US
Practice Address - Phone:239-295-4614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA19490235Z00000X
222Q00000X, 222Q00000X
FLSZ9815235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist