Provider Demographics
NPI:1659968923
Name:CHEBOTAREVA, RENATA PETROVNA (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:RENATA
Middle Name:PETROVNA
Last Name:CHEBOTAREVA
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22443 SE 240TH ST STE B101
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5879
Mailing Address - Country:US
Mailing Address - Phone:425-358-4885
Mailing Address - Fax:425-358-7159
Practice Address - Street 1:22443 SE 240TH ST STE B101
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-5879
Practice Address - Country:US
Practice Address - Phone:425-358-4885
Practice Address - Fax:425-358-7159
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61098071235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist