Provider Demographics
NPI:1104492032
Name:WANNER, SARA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WANNER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5143 REDCOAT LOOP
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-7865
Mailing Address - Country:US
Mailing Address - Phone:701-426-6565
Mailing Address - Fax:
Practice Address - Street 1:1000 E CALGARY AVE STE 1
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5648
Practice Address - Country:US
Practice Address - Phone:701-355-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1953235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist