Provider Demographics
NPI:1427723667
Name:ANDERSON, TAYLOR ANNA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ANNA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:ANNA
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:179 PARK LAWN DR APT 4
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2399
Mailing Address - Country:US
Mailing Address - Phone:208-206-2073
Mailing Address - Fax:
Practice Address - Street 1:240 W BURNSIDE AVE STE D
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-4703
Practice Address - Country:US
Practice Address - Phone:208-904-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-4905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist