Provider Demographics
NPI:1275829186
Name:PERKETT, ANGELA LYNN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:LYNN
Last Name:PERKETT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:LYNN
Other - Last Name:LIDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:9800 45TH AVE N
Mailing Address - Street 2:APT. 111
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2657
Mailing Address - Country:US
Mailing Address - Phone:651-387-6681
Mailing Address - Fax:
Practice Address - Street 1:9800 45TH AVE N
Practice Address - Street 2:APT. 111
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-2657
Practice Address - Country:US
Practice Address - Phone:651-387-6681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8754235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12073055OtherASHA#
MN8754OtherMINNESOTA LICENSE