Provider Demographics
NPI:1215267273
Name:PENROD, SARAMARIE REILLY (SLP)
Entity type:Individual
Prefix:
First Name:SARAMARIE
Middle Name:REILLY
Last Name:PENROD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:MARIE
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3175
Mailing Address - Country:US
Mailing Address - Phone:207-662-0111
Mailing Address - Fax:
Practice Address - Street 1:55 SPRING ST
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8926
Practice Address - Country:US
Practice Address - Phone:207-396-7337
Practice Address - Fax:078-854-3549
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL009801235Z00000X
MESP3030235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist