Basic Information
| Provider Information | |||||||||
| NPI: | 1841227964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NUTLEY | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MHS CCC SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 EDMOND DR | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193221415 | ||||||||
| FaxNumber: | 2193221414 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 EDMOND DR | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193221415 | ||||||||
| FaxNumber: | 2193221414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 09/02/2008 | ||||||||
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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 | 22001692A | IN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 200645490 | 05 | IN | MEDICAID | 200716000A | 05 | IN | MEDICAID |