Provider Demographics
NPI:1255664900
Name:SANFORD, KERRY MARIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:MARIE
Last Name:SANFORD
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10030 EDISON SQUARE DR NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8308
Mailing Address - Country:US
Mailing Address - Phone:704-499-8888
Mailing Address - Fax:
Practice Address - Street 1:10030 EDISON SQUARE DR NW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-8308
Practice Address - Country:US
Practice Address - Phone:704-499-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021907-1235Z00000X
NY190480914235Z00000X
NC10115235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1255664900Medicaid