Provider Demographics
NPI:1891930202
Name:PETRIE, SANDRA LEE (MA CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LEE
Last Name:PETRIE
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 1:662 MANHATTAN CIR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9805
Mailing Address - Country:US
Mailing Address - Phone:630-740-1112
Mailing Address - Fax:
Practice Address - Street 1:662 MANHATTAN CIR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9805
Practice Address - Country:US
Practice Address - Phone:630-740-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-14
Last Update Date:2008-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.009643235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist