Healthcare Provider Details

I. General information

NPI: 1194953331
Provider Name (Legal Business Name): RENEE NICOLE SIDDELL M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RENEE NICOLE SUDA M.S., CCC-SLP

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 W THUNDERBIRD RD
GLENDALE AZ
85306-4002
US

IV. Provider business mailing address

6330 W THUNDERBIRD RD
GLENDALE AZ
85306-4002
US

V. Phone/Fax

Practice location:
  • Phone: 623-486-6010
  • Fax:
Mailing address:
  • Phone: 623-486-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP6247
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberTSLP6247
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: