Basic Information
Provider Information | |||||||||
NPI: | 1407134810 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LINN | ||||||||
FirstName: | AMBER | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MCD, CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 565 WHITEFIELD LN | ||||||||
Address2: |   | ||||||||
City: | BOSSIER CITY | ||||||||
State: | LA | ||||||||
PostalCode: | 711124281 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3184231994 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2522 E 70TH ST | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711054002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3187953388 | ||||||||
FaxNumber: | 3187953399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2011 | ||||||||
LastUpdateDate: | 08/02/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 6267 | LA | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.