Provider Demographics
NPI:1679176440
Name:SAN JOSE, SANDRA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SAN JOSE
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 1:7859 ENCHANTED PATH DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79911-7513
Mailing Address - Country:US
Mailing Address - Phone:732-778-7018
Mailing Address - Fax:
Practice Address - Street 1:7859 ENCHANTED PATH DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79911-7513
Practice Address - Country:US
Practice Address - Phone:732-778-7018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP12375235Z00000X
TX117453235Z00000X
NJ41YS00516600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist