Provider Demographics
NPI:1275935579
Name:PETTEY, SHARON L (SLPA)
Entity Type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:L
Last Name:PETTEY
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19435 SENECA RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-5450
Mailing Address - Country:US
Mailing Address - Phone:909-645-1083
Mailing Address - Fax:
Practice Address - Street 1:16785 BEAR VALLEY RD
Practice Address - Street 2:SUITE 2
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-0825
Practice Address - Country:US
Practice Address - Phone:760-782-8884
Practice Address - Fax:866-496-0434
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16142355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant