Provider Demographics
NPI:1649755091
Name:HARDENBERGH, ANNA GRACE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ANNA
Middle Name:GRACE
Last Name:HARDENBERGH
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Gender:F
Credentials:MA, CCC-SLP
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Mailing Address - Street 1:1500 E. MEDICAL CENTER DRIVE TC 1904
Mailing Address - Street 2:OTOLARYNGOLOGY HEAD AND NECK SURGERY
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109
Mailing Address - Country:US
Mailing Address - Phone:734-936-8051
Mailing Address - Fax:
Practice Address - Street 1:1500 E. MEDICAL CENTER DRIVE TC 1904
Practice Address - Street 2:OTOLARYNGOLOGY HEAD AND NECK SURGERY
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109
Practice Address - Country:US
Practice Address - Phone:734-936-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1003878539Medicaid