Provider Demographics
NPI:1821541608
Name:SEPULVEDA, ANKA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANKA
Middle Name:
Last Name:SEPULVEDA
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 1:7833 SE LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-4157
Mailing Address - Country:US
Mailing Address - Phone:971-313-1887
Mailing Address - Fax:
Practice Address - Street 1:7833 SE LINCOLN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-4157
Practice Address - Country:US
Practice Address - Phone:971-313-1887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60178612235Z00000X
OR13347235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist