Provider Demographics
NPI:1689737801
Name:SANDUSKY, EVANA RUTH (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:EVANA
Middle Name:RUTH
Last Name:SANDUSKY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9689 COUNTY ROAD 975 N
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-2089
Mailing Address - Country:US
Mailing Address - Phone:618-967-2113
Mailing Address - Fax:618-643-3916
Practice Address - Street 1:9689 COUNTY ROAD 975 N
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-2089
Practice Address - Country:US
Practice Address - Phone:618-967-2113
Practice Address - Fax:618-643-3916
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008291235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03332004OtherBLUE CROSS BLUE SHIELD