Provider Demographics
NPI:1467108845
Name:PENNINGTON, RUSTY LEE (MA, CCC/SLP)
Entity Type:Individual
Prefix:MR
First Name:RUSTY
Middle Name:LEE
Last Name:PENNINGTON
Suffix:
Gender:M
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9958 KEIFER VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-4823
Mailing Address - Country:US
Mailing Address - Phone:702-302-6996
Mailing Address - Fax:
Practice Address - Street 1:2785 S RAINBOW BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-4010
Practice Address - Country:US
Practice Address - Phone:702-685-6004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-730235Z00000X
ND2222235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist