Provider Demographics
NPI:1316370943
Name:ANDERSEN, SALLY (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:892 MARGARET ST LOWR
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-4510
Mailing Address - Country:US
Mailing Address - Phone:269-832-0581
Mailing Address - Fax:
Practice Address - Street 1:709 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4804
Practice Address - Country:US
Practice Address - Phone:651-227-8471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9085235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist