Basic Information
| Provider Information | |||||||||
| NPI: | 1700131141 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTIBONE | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | RENE | ||||||||
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| Credential: | MS-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 BRAZIER LN | ||||||||
| Address2: | |||||||||
| City: | KENNEBUNK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040437095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079853030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 188 JONES AVE | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038015516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034312530 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2012 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 22006947A | IN | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 144.0115359 | VT | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SP2394 | ME | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SLP10659 | AZ | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 1481 | NH | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.