Provider Demographics
NPI:1780649103
Name:PETTAY, THERESA F (SLP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:F
Last Name:PETTAY
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 1:21105 SCHOOL VIEW RD
Mailing Address - Street 2:
Mailing Address - City:WAMEGO
Mailing Address - State:KS
Mailing Address - Zip Code:66547-9416
Mailing Address - Country:US
Mailing Address - Phone:785-456-7326
Mailing Address - Fax:
Practice Address - Street 1:21105 SCHOOL VIEW RD
Practice Address - Street 2:
Practice Address - City:WAMEGO
Practice Address - State:KS
Practice Address - Zip Code:66547-9416
Practice Address - Country:US
Practice Address - Phone:785-456-7326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1144235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist