MEDICARE: ERICA JANE SANFORD M.A. CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	14046426	IN

General Provider Information

NPI Number	:	1891139267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA JANE SANFORD M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	2201 14TH AVE NW
Second Line	:
City	:	GIG HARBOR
State	:	WA
Zip	:	98335-1619
Country	:	US
Telephone Number	:	808-292-1119
Fax Number	:

Provider Business Practice Location Address
First Line	:	1864 WELCHWOOD CIR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-5532
Country	:	US
Telephone Number	:	808-292-1119
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2013
Last Update Date	:	01/23/2018

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