Provider Demographics
NPI:1497261325
Name:ANDERSON, PAULA RENE'
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:RENE'
Last Name:ANDERSON
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 1:12951 GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9826
Mailing Address - Country:US
Mailing Address - Phone:312-909-0386
Mailing Address - Fax:
Practice Address - Street 1:12425 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-2701
Practice Address - Country:US
Practice Address - Phone:815-439-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1946456235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist