Provider Demographics
NPI:1619503661
Name:GENDREAU, MIRANDA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:GENDREAU
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16201 25TH AVE W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-2520
Mailing Address - Country:US
Mailing Address - Phone:425-774-9564
Mailing Address - Fax:
Practice Address - Street 1:16201 25TH AVE W
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-2520
Practice Address - Country:US
Practice Address - Phone:425-774-9564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
WA60990987235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist