Provider Demographics
NPI:1104941731
Name:DEMARET, SANDRA MAE (SLP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:MAE
Last Name:DEMARET
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 COUNTY ROAD 1070 N
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-2883
Mailing Address - Country:US
Mailing Address - Phone:618-919-0084
Mailing Address - Fax:
Practice Address - Street 1:1947 COUNTY ROAD 1070 N
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-2883
Practice Address - Country:US
Practice Address - Phone:618-919-0084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146006583235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9632002OtherBLUE SHIELD PROVIDER NUMB