Provider Demographics
NPI:1124434899
Name:DRELLICH, DENISE AUTUMN (SLP)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:AUTUMN
Last Name:DRELLICH
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 1:848 SE WESTMINSTER PL
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-5500
Mailing Address - Country:US
Mailing Address - Phone:772-485-4421
Mailing Address - Fax:
Practice Address - Street 1:848 SE WESTMINSTER PL
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-5500
Practice Address - Country:US
Practice Address - Phone:772-485-4421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4743235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist