Provider Demographics
NPI:1215577184
Name:PENKUNAS, DESIREE MARIAH (SLP)
Entity type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:MARIAH
Last Name:PENKUNAS
Suffix:
Gender:
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4022
Mailing Address - Country:US
Mailing Address - Phone:870-215-3715
Mailing Address - Fax:
Practice Address - Street 1:1910 RECTOR RD
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-2004
Practice Address - Country:US
Practice Address - Phone:870-240-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR200951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200951OtherPROVISIONAL AR LICENSE SPEECH PATHOLOGY