Provider Demographics
NPI:1568943959
Name:REEDY, PENNY (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:REEDY
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MORNINGSIDE
Mailing Address - Street 2:
Mailing Address - City:BULLARD
Mailing Address - State:TX
Mailing Address - Zip Code:75757-5181
Mailing Address - Country:US
Mailing Address - Phone:903-245-2413
Mailing Address - Fax:469-375-5380
Practice Address - Street 1:600 MORNINGSIDE
Practice Address - Street 2:
Practice Address - City:BULLARD
Practice Address - State:TX
Practice Address - Zip Code:75757-5181
Practice Address - Country:US
Practice Address - Phone:903-245-2413
Practice Address - Fax:469-375-5380
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17490235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX17490OtherSTATE OF TEXAS
01121446OtherASHA