Provider Demographics
NPI:1639765100
Name:SUNDERLAND, ANNA IONE
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:IONE
Last Name:SUNDERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:IONE
Other - Last Name:SEVERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:195 TURNBERRY PL APT E
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-4467
Mailing Address - Country:US
Mailing Address - Phone:785-285-2301
Mailing Address - Fax:
Practice Address - Street 1:13612 BIG BEND RD
Practice Address - Street 2:
Practice Address - City:VALLEY PARK
Practice Address - State:MO
Practice Address - Zip Code:63088-1447
Practice Address - Country:US
Practice Address - Phone:636-923-8693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020035172235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist