Provider Demographics
NPI:1003989815
Name:BRAGG, AMY L (MA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:BRAGG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:SECHREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, SLP
Mailing Address - Street 1:797 WILSON ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1003
Mailing Address - Country:US
Mailing Address - Phone:207-947-8493
Mailing Address - Fax:207-990-4819
Practice Address - Street 1:797 WILSON ST STE 2
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1003
Practice Address - Country:US
Practice Address - Phone:207-947-8493
Practice Address - Fax:207-990-4819
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP825235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME252520099Medicaid
ME024794OtherANTHEM
ME024794OtherANTHEM