Provider Demographics
NPI:1962613109
Name:WALDRON, PEGGYANN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:PEGGYANN
Middle Name:
Last Name:WALDRON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 BURRSTONE ROAD
Mailing Address - Street 2:APT. 1B
Mailing Address - City:NEW YORK MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 SHERRILL RD
Practice Address - Street 2:
Practice Address - City:SHERRILL
Practice Address - State:NY
Practice Address - Zip Code:13461-1461
Practice Address - Country:US
Practice Address - Phone:315-363-8288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016422235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02864226Medicaid