Provider Demographics
NPI:1639665938
Name:GLEN, ANDREA SARA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:SARA
Last Name:GLEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18131 FLOWERED MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8715
Mailing Address - Country:US
Mailing Address - Phone:719-800-1192
Mailing Address - Fax:
Practice Address - Street 1:516 W BIJOU ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1311
Practice Address - Country:US
Practice Address - Phone:719-633-9114
Practice Address - Fax:719-329-0495
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0003292235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist