Basic Information
| Provider Information | |||||||||
| NPI: | 1336331446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERLOO | ||||||||
| FirstName: | ANN BETH | ||||||||
| MiddleName: | BAILEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ST | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | VANDERLOO | ||||||||
| OtherFirstName: | BETH | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 950 E COUNTY LINE RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391571928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018539747 | ||||||||
| FaxNumber: | 6018984761 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 E COUNTY LINE RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391571928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018539747 | ||||||||
| FaxNumber: | 6018984761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | S0859 | MS | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 00123119 | 05 | MS | MEDICAID |