Provider Demographics
NPI:1255410122
Name:MEDLEY, REBECCA R (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:R
Last Name:MEDLEY
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 1:2402 SHERRY RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217
Mailing Address - Country:US
Mailing Address - Phone:502-638-0595
Mailing Address - Fax:
Practice Address - Street 1:982 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-635-6397
Practice Address - Fax:502-635-1147
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2127235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000186059OtherANTHEM