Provider Demographics
NPI:1740292101
Name:SANDERSON, ALICE MARY (CCC-A)
Entity type:Individual
Prefix:MS
First Name:ALICE
Middle Name:MARY
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 SKIPSTONE CT
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-2269
Mailing Address - Country:US
Mailing Address - Phone:706-769-3118
Mailing Address - Fax:
Practice Address - Street 1:110 CARLTON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-5004
Practice Address - Country:US
Practice Address - Phone:706-542-2371
Practice Address - Fax:706-542-4574
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1681231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00826141AMedicaid
GA64PCBGNMedicare ID - Type UnspecifiedAUDIOLOGIST