Provider Demographics
NPI:1467625269
Name:MOOG, SANDRA RENEE (MS/CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:RENEE
Last Name:MOOG
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 1:3456 S 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4104
Mailing Address - Country:US
Mailing Address - Phone:414-333-4680
Mailing Address - Fax:
Practice Address - Street 1:3540 S 43RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-1502
Practice Address - Country:US
Practice Address - Phone:414-328-2104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-12
Last Update Date:2008-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2681-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42586400Medicaid