Provider Demographics
NPI:1982795076
Name:WHISONANT, BRENDA LARK (SLP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LARK
Last Name:WHISONANT
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 1:2875 BARN RD
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-6361
Mailing Address - Country:US
Mailing Address - Phone:540-639-5786
Mailing Address - Fax:540-633-0787
Practice Address - Street 1:2875 BARN RD
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6361
Practice Address - Country:US
Practice Address - Phone:540-639-5786
Practice Address - Fax:540-633-0787
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202000928235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA496604Medicare ID - Type UnspecifiedMEDICARE GROUP