Provider Demographics
NPI:1861883464
Name:ANDERSON, BRANDY
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:
Other - Last Name:OTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:925 E DIXON RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206-4115
Mailing Address - Country:US
Mailing Address - Phone:501-234-2000
Mailing Address - Fax:
Practice Address - Street 1:12 SALLISAW CT
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-5327
Practice Address - Country:US
Practice Address - Phone:501-626-5992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2355S0801X2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR204892721Medicaid