Provider Demographics
NPI:1003998915
Name:ANDERSON, TERRY MARIE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:TERRY
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MRS
Other - First Name:TERRY
Other - Middle Name:MARIE
Other - Last Name:ANDERSON BLANKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:1400 W. ICE LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:IRON RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49935
Mailing Address - Country:US
Mailing Address - Phone:906-265-6121
Mailing Address - Fax:
Practice Address - Street 1:1400 W. ICE LAKE ROAD
Practice Address - Street 2:
Practice Address - City:IRON RIVER
Practice Address - State:MI
Practice Address - Zip Code:49935-4993
Practice Address - Country:US
Practice Address - Phone:906-265-6121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2149154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42793400Medicaid
520113Medicare ID - Type Unspecified