Provider Demographics
NPI:1063435451
Name:PENDERGRASS, MERRIE G (SLP)
Entity type:Individual
Prefix:
First Name:MERRIE
Middle Name:G
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 BLAIR DR
Mailing Address - Street 2:LSUHSC-SCHOOL OF ALLIED HEALTH PROFESSIONALS
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4602
Mailing Address - Country:US
Mailing Address - Phone:318-632-2030
Mailing Address - Fax:318-675-5666
Practice Address - Street 1:3730 BLAIR DR
Practice Address - Street 2:LSUHSC-SCHOOL OF ALLIED HEALTH PROFESSIONALS
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4602
Practice Address - Country:US
Practice Address - Phone:318-632-2030
Practice Address - Fax:318-675-5666
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174173Medicaid
LA196550Medicare ID - Type UnspecifiedGROUP MC#