Provider Demographics
NPI:1669745733
Name:PARKS, CONNIE SUE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:SUE
Last Name:PARKS
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 1:4238 67TH AVENUE CIR E
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-5101
Mailing Address - Country:US
Mailing Address - Phone:941-756-8835
Mailing Address - Fax:
Practice Address - Street 1:741 S BENEVA RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-2411
Practice Address - Country:US
Practice Address - Phone:941-957-0310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist