Provider Demographics
NPI:1942035928
Name:SMITH, AMANDA (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 E 150 N
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-6351
Mailing Address - Country:US
Mailing Address - Phone:219-851-8752
Mailing Address - Fax:
Practice Address - Street 1:2255 E 150 N
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-6351
Practice Address - Country:US
Practice Address - Phone:219-851-8752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-07
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22008949A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist