Provider Demographics
NPI:1982228961
Name:ANDERSON, STEPHANIE ELLEN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ELLEN
Last Name:ANDERSON
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 1:401 SE MAIN ST APT 7011
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-4618
Mailing Address - Country:US
Mailing Address - Phone:815-988-8475
Mailing Address - Fax:
Practice Address - Street 1:401 SE MAIN ST APT 7011
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-4618
Practice Address - Country:US
Practice Address - Phone:815-988-8475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10447235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist