Healthcare Provider Details

I. General information

NPI: 1932428877
Provider Name (Legal Business Name): SANDRA M PEASE M.A. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 HARRISON AVE
ROSELAND NJ
07068-1256
US

IV. Provider business mailing address

48 HARRISON AVE
ROSELAND NJ
07068-1256
US

V. Phone/Fax

Practice location:
  • Phone: 973-896-6380
  • Fax:
Mailing address:
  • Phone: 973-896-6380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number014486-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41YS00498200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: