Provider Demographics
NPI:1104122373
Name:SANDIDGE, JOHN LOTT (SLP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LOTT
Last Name:SANDIDGE
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:DEPT 128
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0128
Mailing Address - Country:US
Mailing Address - Phone:901-821-0338
Mailing Address - Fax:901-821-0341
Practice Address - Street 1:640 GLEN IRIS DR NE
Practice Address - Street 2:UNIT 508
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2723
Practice Address - Country:US
Practice Address - Phone:404-277-5813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-04
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004077235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist