Provider Demographics
NPI:1356472153
Name:CODY-MALDEGEN, CONNIE JEAN (SLP)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:JEAN
Last Name:CODY-MALDEGEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2194 CANDELERO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5603
Mailing Address - Country:US
Mailing Address - Phone:505-471-4655
Mailing Address - Fax:
Practice Address - Street 1:1300 CAMINO SIERRA VIS
Practice Address - Street 2:129
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1007
Practice Address - Country:US
Practice Address - Phone:505-467-2504
Practice Address - Fax:505-467-2646
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1382235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ4264Medicaid