Provider Demographics
NPI:1497154355
Name:STATEN, ANDREA CAROL (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:CAROL
Last Name:STATEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MRS
Other - First Name:ANDREA
Other - Middle Name:CAROL
Other - Last Name:SUZYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSCCC-SLP
Mailing Address - Street 1:146 YOCONA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-6904
Mailing Address - Country:US
Mailing Address - Phone:662-934-9885
Mailing Address - Fax:
Practice Address - Street 1:146 YOCONA RIDGE RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-6904
Practice Address - Country:US
Practice Address - Phone:662-934-9885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-17
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2354235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist