Basic Information
Provider Information | |||||||||
NPI: | 1407109234 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS CCC SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NAUMAN | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS CCC SLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 33 DWINELL DR | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NH | ||||||||
PostalCode: | 033012513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6033212693 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 188 JONES AVE | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | NH | ||||||||
PostalCode: | 038015516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034312530 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2012 | ||||||||
LastUpdateDate: | 07/22/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1533 | NH | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | SL011568 | PA | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.