Provider Demographics
NPI:1417149394
Name:PATTERSON, ANDREA L (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:PATTERSON
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 1:2403 MAIN DR STE 5
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-5275
Mailing Address - Country:US
Mailing Address - Phone:479-966-4883
Mailing Address - Fax:479-445-6130
Practice Address - Street 1:2403 MAIN DR STE 5
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5275
Practice Address - Country:US
Practice Address - Phone:479-966-4883
Practice Address - Fax:479-445-6130
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004667235Z00000X
ARSP#1388235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000842003DMedicaid
AR134548721Medicaid