Provider Demographics
NPI:1972949139
Name:PIERSON, CONNIE R (SLP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:R
Last Name:PIERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:R
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 WINDSOR PATH
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9617
Mailing Address - Country:US
Mailing Address - Phone:859-588-3709
Mailing Address - Fax:502-603-0622
Practice Address - Street 1:105 WINDSOR PATH
Practice Address - Street 2:SUITE 3
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9617
Practice Address - Country:US
Practice Address - Phone:859-588-3709
Practice Address - Fax:502-603-0622
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY142321235Z00000X
KY0868235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100270860Medicaid
KY000000818511OtherANTHEM
KY7100270860Medicaid