Basic Information
| Provider Information | |||||||||
| NPI: | 1487741930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGWELL | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.S. CCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 MORGANTOWN AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265544513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043668498 | ||||||||
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| Practice Location | |||||||||
| Address1: | 230 GRANDE MDWS | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263309711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045922009 | ||||||||
| FaxNumber: | 3045922004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP-0901 | WV | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 7402351-000 | 05 | WV | MEDICAID |