Provider Demographics
NPI:1427166966
Name:PRIDEAUX, MOLLY ANN
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:PRIDEAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:ANN
Other - Last Name:LANCASTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:5288 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3306
Mailing Address - Country:US
Mailing Address - Phone:541-510-3482
Mailing Address - Fax:
Practice Address - Street 1:19185 SW 90TH AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7558
Practice Address - Country:US
Practice Address - Phone:503-885-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12646235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist