Provider Demographics
NPI:1609200138
Name:SANDROCK, MADISON (MA, CF-SLP)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:SANDROCK
Suffix:
Gender:F
Credentials:MA, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20493 BREEZEWAY DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-3517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8481 HOLLY RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1812
Practice Address - Country:US
Practice Address - Phone:810-649-6382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001631235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist