Provider Demographics
NPI:1104054246
Name:DENNIS, DIEDRE ANNE (MA, CCC/SLP)
Entity type:Individual
Prefix:
First Name:DIEDRE
Middle Name:ANNE
Last Name:DENNIS
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 EISENHOWER AVE
Mailing Address - Street 2:SUITE #234
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4698
Mailing Address - Country:US
Mailing Address - Phone:703-850-0872
Mailing Address - Fax:
Practice Address - Street 1:2121 EISENHOWER AVE
Practice Address - Street 2:SUITE #234
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4698
Practice Address - Country:US
Practice Address - Phone:703-850-0872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004567235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist