Provider Demographics
NPI:1063062917
Name:IMMORDINO-SANDERSON, ELISE HELEN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:HELEN
Last Name:IMMORDINO-SANDERSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:HELEN
Other - Last Name:IMMORDINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1610 WENDY LN
Mailing Address - Street 2:
Mailing Address - City:EFLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27243-9675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3102 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-9199
Practice Address - Country:US
Practice Address - Phone:336-350-9263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13741235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist