Provider Demographics
NPI:1770232811
Name:JOHNSON CITY SPEECH AND LANGUAGE THERAPY
Entity type:Organization
Organization Name:JOHNSON CITY SPEECH AND LANGUAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DORI
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC/SLP
Authorized Official - Phone:423-212-3853
Mailing Address - Street 1:2700 S ROAN ST STE 425
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-7587
Mailing Address - Country:US
Mailing Address - Phone:423-212-3853
Mailing Address - Fax:423-805-1741
Practice Address - Street 1:2700 S ROAN ST STE 425
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-7587
Practice Address - Country:US
Practice Address - Phone:423-212-3853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-23
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ079383Medicaid