MEDICARE: KELLY SANDERSON M.S., 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	7101001457	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184741290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY SANDERSON M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	3781 S CRUZEN RD
Second Line	:
City	:	MIKADO
State	:	MI
Zip	:	48745-8761
Country	:	US
Telephone Number	:	989-335-3942
Fax Number	:

Provider Business Practice Location Address
First Line	:	1691 E US 23 STE 4
Second Line	:
City	:	EAST TAWAS
State	:	MI
Zip	:	48730-9337
Country	:	US
Telephone Number	:	989-479-7550
Fax Number	:

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

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	07/25/2023

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Directions to “ KELLY SANDERSON M.S., CCC-SLP” Practice Location

Language	Start Address	Practice Location

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