Provider Demographics
NPI:1598052037
Name:PENNINGTON, MARISA
Entity Type:Individual
Prefix:MS
First Name:MARISA
Middle Name:
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257C WOODCHASE LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-9756
Mailing Address - Country:US
Mailing Address - Phone:314-453-1630
Mailing Address - Fax:
Practice Address - Street 1:1257C WOODCHASE LN
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-9756
Practice Address - Country:US
Practice Address - Phone:314-453-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008031882235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist