Basic Information
| Provider Information | |||||||||
| NPI: | 1104122373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDIDGE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | LOTT | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | DEPT 128 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018210338 | ||||||||
| FaxNumber: | 9018210341 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 GLEN IRIS DR NE | ||||||||
| Address2: | UNIT 508 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042775813 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2011 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP004077 | GA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.