Provider Demographics
NPI:1063844553
Name:CHRISTENSON, MANDA RAE (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:MANDA
Middle Name:RAE
Last Name:CHRISTENSON
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15625 CEDAR LANE
Mailing Address - Street 2:
Mailing Address - City:BASEHOR
Mailing Address - State:KS
Mailing Address - Zip Code:66012
Mailing Address - Country:US
Mailing Address - Phone:785-304-1600
Mailing Address - Fax:
Practice Address - Street 1:15625 CEDAR LN
Practice Address - Street 2:
Practice Address - City:BASEHOR
Practice Address - State:KS
Practice Address - Zip Code:66012-7380
Practice Address - Country:US
Practice Address - Phone:785-304-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2296235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist