Provider Demographics
NPI:1164690533
Name:ANDERSON, REGINA MARIE (SLP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14913 SE STEVENSON DR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8352
Mailing Address - Country:US
Mailing Address - Phone:615-945-7378
Mailing Address - Fax:
Practice Address - Street 1:14913 SE STEVENSON DR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-8352
Practice Address - Country:US
Practice Address - Phone:615-945-7378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004783235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist