Provider Demographics
NPI:1902102551
Name:WICKHAM BRODIE, PENNY (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:
Last Name:WICKHAM BRODIE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SAINT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-2118
Mailing Address - Country:US
Mailing Address - Phone:845-794-4020
Mailing Address - Fax:
Practice Address - Street 1:22 TANNERY RD
Practice Address - Street 2:
Practice Address - City:FORESTBURGH
Practice Address - State:NY
Practice Address - Zip Code:12777-6100
Practice Address - Country:US
Practice Address - Phone:845-707-4936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0007772-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist