Provider Demographics
NPI:1942303284
Name:DESORMES, PUNAM (CCC-SLP, ATP)
Entity Type:Individual
Prefix:MRS
First Name:PUNAM
Middle Name:
Last Name:DESORMES
Suffix:
Gender:F
Credentials:CCC-SLP, ATP
Other - Prefix:MRS
Other - First Name:PUNAM
Other - Middle Name:
Other - Last Name:ENGINEER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:358 BRASSIE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-3008
Mailing Address - Country:US
Mailing Address - Phone:407-341-9524
Mailing Address - Fax:
Practice Address - Street 1:3280 PROGRESS DR STE 500
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-2903
Practice Address - Country:US
Practice Address - Phone:407-882-0468
Practice Address - Fax:407-882-0483
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8228235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891091000Medicaid
FLSA 8228OtherFL LICENSE
FL13425701OtherCITRUS HEALTHCARE ID