Basic Information
| Provider Information | |||||||||
| NPI: | 1205054962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MACCC SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 522 | ||||||||
| Address2: | |||||||||
| City: | COUDERSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142741125 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 CAMPUS DRIVE | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148875591 | ||||||||
| FaxNumber: | 8148875666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SL005631L | PA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 0018796260002 | 05 | PA | MEDICAID |