Provider Demographics
NPI:1629309216
Name:RAUCH, SALLY ANN (CCCSLP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:RAUCH
Suffix:
Gender:M
Credentials:CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 N KINGSTON PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-4415
Mailing Address - Country:US
Mailing Address - Phone:918-671-6314
Mailing Address - Fax:918-834-9819
Practice Address - Street 1:2425 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-2617
Practice Address - Country:US
Practice Address - Phone:918-628-0932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist