Provider Demographics
NPI:1750463915
Name:ANDERSON, CHRISTINE TRACY
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:TRACY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N73W7135 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-1131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10602 N PORT WASHINGTON RD
Practice Address - Street 2:101
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5079
Practice Address - Country:US
Practice Address - Phone:262-241-8030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI625-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist