Basic Information
| Provider Information | |||||||||
| NPI: | 1689197071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHILDERS | ||||||||
| FirstName: | AMANDA | ||||||||
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| Credential: | SLP ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 NE LOOP 820 BUSINESS TOWER 1 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172928787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 14515 BRIARHILLS PKWY STE 208 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770771034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135752000 | ||||||||
| FaxNumber: | 7135752031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2017 | ||||||||
| LastUpdateDate: | 07/18/2017 | ||||||||
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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 | 2355S0801X | 35049 | TX | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
ID Information
| ID | Type | State | Issuer | Description | 23 | 05 | TX | MEDICAID |