Provider Demographics
NPI:1891817995
Name:PENDLETON, LINDA JEAN (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:JEAN
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10901 BRIGHTON BAY BLVD NE
Mailing Address - Street 2:APT 1103
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3446
Mailing Address - Country:US
Mailing Address - Phone:727-563-9727
Mailing Address - Fax:
Practice Address - Street 1:10901 BRIGHTON BAY BLVD NE
Practice Address - Street 2:APT 1103
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-3446
Practice Address - Country:US
Practice Address - Phone:727-563-9727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8656235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8916411Medicaid