Basic Information
Provider Information | |||||||||
NPI: | 1639765100 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SUNDERLAND | ||||||||
FirstName: | ANNA | ||||||||
MiddleName: | IONE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SEVERSON | ||||||||
OtherFirstName: | ANNA | ||||||||
OtherMiddleName: | IONE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 195 TURNBERRY PL APT E | ||||||||
Address2: |   | ||||||||
City: | SAINT PETERS | ||||||||
State: | MO | ||||||||
PostalCode: | 633764467 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7852852301 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13612 BIG BEND RD | ||||||||
Address2: |   | ||||||||
City: | VALLEY PARK | ||||||||
State: | MO | ||||||||
PostalCode: | 630881447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6369238693 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/17/2020 | ||||||||
LastUpdateDate: | 12/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2020035172 | MO | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.