Provider Demographics
NPI:1407108996
Name:PERNACCHIO, AMY SUSAN (CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:AMY
Middle Name:SUSAN
Last Name:PERNACCHIO
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 1:57 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02540-2652
Mailing Address - Country:US
Mailing Address - Phone:203-464-0322
Mailing Address - Fax:
Practice Address - Street 1:359 JONES RD
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-3341
Practice Address - Country:US
Practice Address - Phone:508-457-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8395235Z00000X
CT004387235Z00000X
RISP01163235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist