Provider Demographics
NPI:1609208651
Name:ANDERSON, VICKI LYNN
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
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 1:3500 ELLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1102
Mailing Address - Country:US
Mailing Address - Phone:704-336-3255
Mailing Address - Fax:704-336-2423
Practice Address - Street 1:3500 ELLINGTON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1102
Practice Address - Country:US
Practice Address - Phone:704-336-3255
Practice Address - Fax:704-336-2423
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1615235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist