Provider Demographics
NPI:1932261096
Name:PEDERSEN, VIRGINIA SHERYL (MS SLP-CCC)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:SHERYL
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MS SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1817
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-1817
Mailing Address - Country:US
Mailing Address - Phone:928-241-1141
Mailing Address - Fax:928-524-6367
Practice Address - Street 1:NAVAJO RT 12
Practice Address - Street 2:WINDOW ROCK UNIFIED SCHOOL DISTRICT
Practice Address - City:FT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-6757
Practice Address - Fax:928-524-6367
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP5025235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ119272Medicaid