Provider Demographics
NPI:1962855015
Name:ANDERSON, NEELEY
Entity Type:Individual
Prefix:
First Name:NEELEY
Middle Name:
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 1:4824 MCKNIGHT RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0935
Mailing Address - Country:US
Mailing Address - Phone:903-793-6135
Mailing Address - Fax:903-793-0053
Practice Address - Street 1:4824 MCKNIGHT RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0935
Practice Address - Country:US
Practice Address - Phone:903-793-6135
Practice Address - Fax:903-793-0053
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113353235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113353OtherSPEECH LANGUAGE PATHOLOGIST LICENSE