Provider Demographics
NPI:1104126895
Name:RATHBURN, NANCY SANSOM (MACCC-SLP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:SANSOM
Last Name:RATHBURN
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5601
Mailing Address - Country:US
Mailing Address - Phone:260-484-3120
Mailing Address - Fax:260-969-0104
Practice Address - Street 1:3320 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5601
Practice Address - Country:US
Practice Address - Phone:260-484-3120
Practice Address - Fax:260-969-0104
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22001327A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist