Provider Demographics
NPI:1780779223
Name:HERNDON, ANITA GAIL (CCC-MS-SLP)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:GAIL
Last Name:HERNDON
Suffix:
Gender:F
Credentials:CCC-MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 GEORGE ROBINSON ROAD
Mailing Address - Street 2:
Mailing Address - City:HAZEL
Mailing Address - State:KY
Mailing Address - Zip Code:42049
Mailing Address - Country:US
Mailing Address - Phone:270-492-8656
Mailing Address - Fax:270-492-8628
Practice Address - Street 1:301 GEORGE ROBINSON ROAD
Practice Address - Street 2:
Practice Address - City:HAZEL
Practice Address - State:KY
Practice Address - Zip Code:42049
Practice Address - Country:US
Practice Address - Phone:270-492-8656
Practice Address - Fax:270-492-8628
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1288OtherFIRST STEPS BILLING NUMBE