Provider Demographics
NPI:1467597583
Name:FENANDER, REBECCA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:FENANDER
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 1:2766 E 2850 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109
Mailing Address - Country:US
Mailing Address - Phone:206-369-9644
Mailing Address - Fax:253-854-7025
Practice Address - Street 1:10811 SE KENT KANGLEY RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7108
Practice Address - Country:US
Practice Address - Phone:253-854-5660
Practice Address - Fax:253-854-7025
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004407235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7018518Medicaid
WA7018518Medicaid