Provider Demographics
NPI:1740213172
Name:BISE, PENNY MARIE (SLP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:MARIE
Last Name:BISE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 BAYOU CIR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-4600
Mailing Address - Country:US
Mailing Address - Phone:228-209-5849
Mailing Address - Fax:228-523-4518
Practice Address - Street 1:400 VETERANS AVE
Practice Address - Street 2:ASPS 126
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2410
Practice Address - Country:US
Practice Address - Phone:228-523-5488
Practice Address - Fax:228-523-4518
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS0277235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist