Provider Demographics
NPI:1952987877
Name:STIDHAM, PRENTISS (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PRENTISS
Middle Name:
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:MED, CCC-SLP
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 6425
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-6425
Mailing Address - Country:US
Mailing Address - Phone:865-742-4929
Mailing Address - Fax:
Practice Address - Street 1:906 N BRIARCLIFF CIR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-6445
Practice Address - Country:US
Practice Address - Phone:865-742-4929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist