Basic Information
| Provider Information | |||||||||
| NPI: | 1396895470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAREKAT | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS SLP CF | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREGORY | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS SLP CF | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17852 LAKE CARLTON DR | ||||||||
| Address2: | APT A | ||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335580302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132436076 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Practice Location | |||||||||
| Address1: | 17852 LAKE CARLTON DR | ||||||||
| Address2: | APT A | ||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335580302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132436076 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SZ3746 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 354957 | 01 | FL | WELLCARE | OTHER | 890741200 | 05 | FL | MEDICAID |