Provider Demographics
NPI:1801928221
Name:DEDRICK, MARSHA LEE (SLP)
Entity type:Individual
Prefix:
First Name:MARSHA
Middle Name:LEE
Last Name:DEDRICK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 N TWYMAN RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64058-3200
Mailing Address - Country:US
Mailing Address - Phone:816-650-7371
Mailing Address - Fax:816-650-7355
Practice Address - Street 1:2101 N TWYMAN RD
Practice Address - Street 2:FORT OSAGE R-I SCHOOL DISTRICT
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64058-3200
Practice Address - Country:US
Practice Address - Phone:816-650-7371
Practice Address - Fax:816-650-7355
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01420235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO466727427Medicaid