Basic Information
| Provider Information | |||||||||
| NPI: | 1275162562 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMY SHANDY, SPEECH-LANGUAGE PATHOLOGIST, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3625 CITADEL DR S | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195970822 | ||||||||
| FaxNumber: | 7195994606 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 N SANTA FE AVE | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808171738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195970822 | ||||||||
| FaxNumber: | 7155994606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2020 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | NEWMAN | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7195970822 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMY SHANDY, SPEECH-LANGUAGE PATHOLOGIST, LLC | ||||||||
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| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.