Provider Demographics
NPI:1881765923
Name:ANDEREGG, PAMELA POWELL (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:POWELL
Last Name:ANDEREGG
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 1:519 RALPH RAHN RD
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-3119
Mailing Address - Country:US
Mailing Address - Phone:912-547-1643
Mailing Address - Fax:912-754-6137
Practice Address - Street 1:519 RALPH RAHN RD
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-3119
Practice Address - Country:US
Practice Address - Phone:912-547-1643
Practice Address - Fax:912-754-6137
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001788235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10034311OtherAMERIGROUP
GA340365OtherWELLCARE