Provider Demographics
NPI:1952366379
Name:VAN LANEN, SALLY ANNE (MSSLP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANNE
Last Name:VAN LANEN
Suffix:
Gender:F
Credentials:MSSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 COUNTY ROAD 67.3
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-9536
Mailing Address - Country:US
Mailing Address - Phone:719-859-3145
Mailing Address - Fax:
Practice Address - Street 1:101 N 2ND ST
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-3803
Practice Address - Country:US
Practice Address - Phone:505-445-7090
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3904235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist