Provider Demographics
NPI:1124643101
Name:FORMICA, ANNA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:FORMICA
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 1:1708 W ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4596
Mailing Address - Country:US
Mailing Address - Phone:410-578-8600
Mailing Address - Fax:
Practice Address - Street 1:1708 W ROGERS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-4596
Practice Address - Country:US
Practice Address - Phone:410-578-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09391235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist