Healthcare Provider Details

I. General information

NPI: 1710008529
Provider Name (Legal Business Name): MRS. CONNIE CUDDEBACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

469 WEADLEY RD
WAYNE PA
19087-1934
US

IV. Provider business mailing address

469 WEADLEY RD
WAYNE PA
19087-1934
US

V. Phone/Fax

Practice location:
  • Phone: 610-971-0927
  • Fax:
Mailing address:
  • Phone: 610-971-0927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL005066L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: