Provider Demographics
NPI:1861090375
Name:MORAN, AMANDA MARY (MS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARY
Last Name:MORAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WHARTON PL
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4261
Mailing Address - Country:US
Mailing Address - Phone:631-708-6927
Mailing Address - Fax:
Practice Address - Street 1:17 WHARTON PL
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4261
Practice Address - Country:US
Practice Address - Phone:631-708-6927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030030-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY030030-01OtherNEW YORK STATE SPEECH-LANGUAGE PATHOLOGIST