Provider Demographics
NPI:1295383610
Name:SUDDERTH, JULIE ANNE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JULIE ANNE
Middle Name:
Last Name:SUDDERTH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2127 ROCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-5723
Mailing Address - Country:US
Mailing Address - Phone:337-257-3183
Mailing Address - Fax:
Practice Address - Street 1:2127 ROCKWOOD DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-5723
Practice Address - Country:US
Practice Address - Phone:337-257-3183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115316235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5786Medicaid