Provider Demographics
NPI:1225157662
Name:SANDA, SUSAN WATKINS (SLP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:WATKINS
Last Name:SANDA
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 1:5821 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-2410
Mailing Address - Country:US
Mailing Address - Phone:952-401-4242
Mailing Address - Fax:
Practice Address - Street 1:464 2ND ST STE 106
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-2108
Practice Address - Country:US
Practice Address - Phone:952-401-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7713235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN206949100Medicare UPIN