Provider Demographics
NPI:1073093092
Name:MAXIM, AMANDA ROSE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:MAXIM
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 1:8114 COUNTRY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41102-9738
Mailing Address - Country:US
Mailing Address - Phone:304-216-1119
Mailing Address - Fax:
Practice Address - Street 1:1104 BOB MCCULLOUGH DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-9275
Practice Address - Country:US
Practice Address - Phone:606-928-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist