Provider Demographics
NPI:1831311133
Name:ROUSE, SARA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:ROUSE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 BAYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1209 W TOKAY ST
Practice Address - Street 2:STE 8
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3845
Practice Address - Country:US
Practice Address - Phone:209-334-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP10185235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist