Provider Demographics
NPI:1770656944
Name:PETTICREW, LINDA DIANNE (MED CCC-A)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:DIANNE
Last Name:PETTICREW
Suffix:
Gender:F
Credentials:MED CCC-A
Other - Prefix:
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Mailing Address - Street 1:102 WEST PINELOCH AVENUE
Mailing Address - Street 2:SUITE 23
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-6100
Mailing Address - Country:US
Mailing Address - Phone:407-481-7173
Mailing Address - Fax:407-481-7190
Practice Address - Street 1:1300 KUHL AVE
Practice Address - Street 2:MP 116
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2006
Practice Address - Country:US
Practice Address - Phone:321-841-6144
Practice Address - Fax:407-649-8869
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAY1005231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811091300Medicaid
FL600419900Medicaid