Provider Demographics
NPI:1477843589
Name:LANDRETH, MARCY G (MS, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:G
Last Name:LANDRETH
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 E BRIARWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2354
Mailing Address - Country:US
Mailing Address - Phone:405-642-5794
Mailing Address - Fax:
Practice Address - Street 1:5 E BRIARWOOD ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2354
Practice Address - Country:US
Practice Address - Phone:405-642-5794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-10
Last Update Date:2011-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2180235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist