Provider Demographics
NPI:1184741290
Name:SANDERSON, KELLY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3781 S CRUZEN RD
Mailing Address - Street 2:
Mailing Address - City:MIKADO
Mailing Address - State:MI
Mailing Address - Zip Code:48745-8761
Mailing Address - Country:US
Mailing Address - Phone:989-335-3942
Mailing Address - Fax:
Practice Address - Street 1:1691 E US 23 STE 4
Practice Address - Street 2:
Practice Address - City:EAST TAWAS
Practice Address - State:MI
Practice Address - Zip Code:48730-9337
Practice Address - Country:US
Practice Address - Phone:989-479-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001457235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100462120Medicaid
IN100462120Medicaid