Provider Demographics
NPI:1033453444
Name:WHITAKER, ANDREA VIOLET (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:VIOLET
Last Name:WHITAKER
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 1:842 LANE 13
Mailing Address - Street 2:
Mailing Address - City:LOVELL
Mailing Address - State:WY
Mailing Address - Zip Code:82431-9523
Mailing Address - Country:US
Mailing Address - Phone:307-548-6722
Mailing Address - Fax:307-548-6700
Practice Address - Street 1:435 E 5TH ST
Practice Address - Street 2:
Practice Address - City:LOVELL
Practice Address - State:WY
Practice Address - Zip Code:82431-1947
Practice Address - Country:US
Practice Address - Phone:307-548-6722
Practice Address - Fax:307-548-6700
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP/CFY-622235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist