Provider Demographics
NPI:1861537243
Name:THOMAS, AMY KENNEDY (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:KENNEDY
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 CHIPPEWA TRL
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4045
Mailing Address - Country:US
Mailing Address - Phone:407-924-5430
Mailing Address - Fax:
Practice Address - Street 1:22 LAKE BEAUTY DR
Practice Address - Street 2:SUITE 304
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2037
Practice Address - Country:US
Practice Address - Phone:407-924-5430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8916235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890769200Medicaid
FLSA 8916OtherSTATE LICENSE NUMBER