Provider Demographics
NPI:1457619850
Name:SHADRICK, REGGIE PEREZ (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:REGGIE
Middle Name:PEREZ
Last Name:SHADRICK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4877 HEARTLAND ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-8105
Mailing Address - Country:US
Mailing Address - Phone:407-249-3095
Mailing Address - Fax:
Practice Address - Street 1:4877 HEARTLAND ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32829-8105
Practice Address - Country:US
Practice Address - Phone:407-249-3095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7711235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist