Healthcare Provider Details

I. General information

NPI: 1790955276
Provider Name (Legal Business Name): SARAH PENDERGAST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 UPLAND RD
MERION STATION PA
19066-1821
US

IV. Provider business mailing address

6432 OAKLEY ST
PHILA PA
19111-5250
US

V. Phone/Fax

Practice location:
  • Phone: 267-241-3632
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL008877
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1021005720001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: