Provider Demographics
NPI:1184929218
Name:ANDERSON, RAQUEL TERESA (PHD)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:TERESA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S JORDAN AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-7002
Mailing Address - Country:US
Mailing Address - Phone:812-855-4161
Mailing Address - Fax:812-855-5531
Practice Address - Street 1:200 S JORDAN AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7002
Practice Address - Country:US
Practice Address - Phone:812-855-4161
Practice Address - Fax:812-855-5531
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005226A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist