Basic Information
| Provider Information | |||||||||
| NPI: | 1750443586 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENZLER | ||||||||
| FirstName: | AMANDA | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 PLANTATION PARK DR. | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299109001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438156999 | ||||||||
| FaxNumber: | 8438156998 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 PLANTATION PARK DR. | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | BLUFFTONO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299109001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438156999 | ||||||||
| FaxNumber: | 8438156998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 08/04/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP006221 | GA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 993218634A | 05 | GA | MEDICAID |