1770656944 NPI number — MS. LINDA DIANNE PETTICREW M.ED. CCC-A

Table of content: MS. LINDA DIANNE PETTICREW M.ED. CCC-A (NPI 1770656944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770656944 NPI number — MS. LINDA DIANNE PETTICREW M.ED. CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTICREW
Provider First Name:
LINDA
Provider Middle Name:
DIANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED. CCC-A
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:
1770656944
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 WEST PINELOCH AVENUE
Provider Second Line Business Mailing Address:
SUITE 23
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32806-6100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-481-7173
Provider Business Mailing Address Fax Number:
407-481-7190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 KUHL AVE
Provider Second Line Business Practice Location Address:
MP 116
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32806-2006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-841-6144
Provider Business Practice Location Address Fax Number:
407-649-8869
Provider Enumeration Date:
11/16/2006

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: 231H00000X , with the licence number:  AY1005 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 811091300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 600419900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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