Provider Demographics
NPI:1639238645
Name:MCKINNIS, SANDRA K (MA, CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:K
Last Name:MCKINNIS
Suffix:
Gender:F
Credentials:MA, CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 LAUREL ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5338
Mailing Address - Country:US
Mailing Address - Phone:907-562-3994
Mailing Address - Fax:907-562-3994
Practice Address - Street 1:4325 LAUREL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5338
Practice Address - Country:US
Practice Address - Phone:907-562-3994
Practice Address - Fax:907-562-3994
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK17235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKSP0600Medicaid