Provider Demographics
NPI:1679522155
Name:PETTIFORD, MARLENE ANN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:ANN
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MISS
Other - First Name:MARLENE
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:2242 TIMBERCREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-4001
Mailing Address - Country:US
Mailing Address - Phone:812-378-6098
Mailing Address - Fax:812-378-6098
Practice Address - Street 1:2242 TIMBERCREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-4001
Practice Address - Country:US
Practice Address - Phone:812-378-6098
Practice Address - Fax:812-378-6098
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003457A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist