Provider Demographics
NPI:1053965525
Name:ANDERSON, IMANI (CCC-SLP)
Entity type:Individual
Prefix:
First Name:IMANI
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 SWEETWATER RD 413
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044
Mailing Address - Country:US
Mailing Address - Phone:610-393-7446
Mailing Address - Fax:
Practice Address - Street 1:2775 CRUSE RD SUITE 2002
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044
Practice Address - Country:US
Practice Address - Phone:770-289-0308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010704235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist