Provider Demographics
NPI:1548790140
Name:HEERDE, SALLY MINER (CCC- SLP)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:MINER
Last Name:HEERDE
Suffix:
Gender:F
Credentials:CCC- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 FAIRWAY CIR
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-2562
Mailing Address - Country:US
Mailing Address - Phone:978-333-9653
Mailing Address - Fax:
Practice Address - Street 1:38 FAIRWAY CIRCLE
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760
Practice Address - Country:US
Practice Address - Phone:978-333-9653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA645235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA00716605OtherASHA CERTIFICATION
MA645OtherSPEECH PATHOLOGY LICENSE