Provider Demographics
NPI:1003154329
Name:DOUGLASS, AMY MICHELLE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MICHELLE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 NE 38TH TER
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34470-8176
Mailing Address - Country:US
Mailing Address - Phone:352-895-5803
Mailing Address - Fax:
Practice Address - Street 1:521 NE 25TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-7034
Practice Address - Country:US
Practice Address - Phone:352-401-7916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10624235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist