Provider Demographics
NPI:1376141473
Name:KHAN, SIDRAH AMHED
Entity Type:Individual
Prefix:
First Name:SIDRAH
Middle Name:AMHED
Last Name:KHAN
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 1:1425 N 12TH AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2457
Mailing Address - Country:US
Mailing Address - Phone:201-281-9672
Mailing Address - Fax:
Practice Address - Street 1:1351 WISCONSIN RIVER DR
Practice Address - Street 2:
Practice Address - City:PORT EDWARDS
Practice Address - State:WI
Practice Address - Zip Code:54469-1099
Practice Address - Country:US
Practice Address - Phone:715-885-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5104-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist