Provider Demographics
NPI:1033341961
Name:CHASTAIN, AMANDA MOORE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MOORE
Last Name:CHASTAIN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
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Mailing Address - Street 1:2035 REGENCY RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2333
Mailing Address - Country:US
Mailing Address - Phone:859-402-1553
Mailing Address - Fax:859-402-1553
Practice Address - Street 1:2035 REGENCY RD
Practice Address - Street 2:SUITE 5
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2333
Practice Address - Country:US
Practice Address - Phone:859-402-1553
Practice Address - Fax:859-402-1553
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3648235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100286880Medicaid
KY000000648031OtherANTHEM
KY000000648031OtherANTHEM