Provider Demographics
NPI:1164862603
Name:MANDA, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:MANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16216 BAXTER RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4770
Mailing Address - Country:US
Mailing Address - Phone:636-733-3330
Mailing Address - Fax:
Practice Address - Street 1:16216 BAXTER RD
Practice Address - Street 2:SUITE 330
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4770
Practice Address - Country:US
Practice Address - Phone:636-733-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011784235Z00000X
MO2014032460235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist