Healthcare Provider Details

I. General information

NPI: 1699229880
Provider Name (Legal Business Name): RENUKA PONNIAH M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 PIERCE AVE NE
RENTON WA
98056-3374
US

IV. Provider business mailing address

4301 S PINE ST STE 301
TACOMA WA
98409-7206
US

V. Phone/Fax

Practice location:
  • Phone: 360-521-4209
  • Fax:
Mailing address:
  • Phone: 253-476-6550
  • Fax: 253-476-6547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: