1902102551 NPI number — MRS. PENNY WICKHAM BRODIE CCC-SLP

Table of content: MRS. PENNY WICKHAM BRODIE CCC-SLP (NPI 1902102551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902102551 NPI number — MRS. PENNY WICKHAM BRODIE CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKHAM BRODIE
Provider First Name:
PENNY
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902102551
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 SAINT JOHN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12701-2118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-794-4020
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 TANNERY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORESTBURGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12777-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-707-4936
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  0007772-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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