Provider Demographics
NPI:1821322306
Name:HENNESSY, ROBYN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 COLLINS AVE
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3002
Mailing Address - Country:US
Mailing Address - Phone:701-663-9531
Mailing Address - Fax:701-663-0328
Practice Address - Street 1:309 COLLINS AVE
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3002
Practice Address - Country:US
Practice Address - Phone:701-663-9531
Practice Address - Fax:701-663-0328
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1069235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55488Medicaid