Provider Demographics
NPI:1669007902
Name:PENNE, DAVINA-MARIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DAVINA-MARIE
Middle Name:
Last Name:PENNE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:DAVINA-MARIE
Other - Middle Name:
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-2117
Mailing Address - Country:US
Mailing Address - Phone:608-235-0521
Mailing Address - Fax:
Practice Address - Street 1:210 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-2117
Practice Address - Country:US
Practice Address - Phone:608-235-0521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4908235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist