Provider Demographics
NPI:1700106994
Name:MASSEY, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MASSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 HIGHWAY 62 E STE 1
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:AR
Mailing Address - Zip Code:72576-9852
Mailing Address - Country:US
Mailing Address - Phone:870-895-2456
Mailing Address - Fax:
Practice Address - Street 1:313 HIGHWAY 62 E STE 1
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576-9852
Practice Address - Country:US
Practice Address - Phone:870-895-2456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR910235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129025721Medicaid