Provider Demographics
NPI:1700131141
Name:PETTIBONE, CHELSEA RENE (MS-SLP)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:RENE
Last Name:PETTIBONE
Suffix:
Gender:F
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BRAZIER LN
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-7095
Mailing Address - Country:US
Mailing Address - Phone:207-985-3030
Mailing Address - Fax:
Practice Address - Street 1:188 JONES AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5516
Practice Address - Country:US
Practice Address - Phone:603-431-2530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006947A235Z00000X
VT144.0115359235Z00000X
MESP2394235Z00000X
AZSLP10659235Z00000X
NH1481235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist