Provider Demographics
NPI:1629875174
Name:PETTRY, MADELINE JEAN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:JEAN
Last Name:PETTRY
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 1:20 NANCY ST
Mailing Address - Street 2:
Mailing Address - City:SETH
Mailing Address - State:WV
Mailing Address - Zip Code:25181-9580
Mailing Address - Country:US
Mailing Address - Phone:304-553-2734
Mailing Address - Fax:
Practice Address - Street 1:1015 OAKHURST DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2049
Practice Address - Country:US
Practice Address - Phone:304-345-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1054235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist