Provider Demographics
NPI:1922720382
Name:PENROD, ELIZABETH BOTTS (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BOTTS
Last Name:PENROD
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 1:857 SE FORGAL ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2781
Mailing Address - Country:US
Mailing Address - Phone:772-631-9366
Mailing Address - Fax:
Practice Address - Street 1:857 SE FORGAL ST
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-2781
Practice Address - Country:US
Practice Address - Phone:772-631-9366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6836235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist