Provider Demographics
NPI:1245309053
Name:SKIPPER, SANDRA LANE (AUD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LANE
Last Name:SKIPPER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10239 CLEMSON BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-0861
Mailing Address - Country:US
Mailing Address - Phone:864-888-8865
Mailing Address - Fax:864-888-3838
Practice Address - Street 1:10239 CLEMSON BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-0861
Practice Address - Country:US
Practice Address - Phone:864-888-8865
Practice Address - Fax:864-888-3838
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC465231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4340Medicaid
SCQ332350281Medicare ID - Type UnspecifiedMEDICARE NUMBER