Provider Demographics
NPI:1083059315
Name:DEICHERT, AMY LEE (MS-SP-CCC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LEE
Last Name:DEICHERT
Suffix:
Gender:F
Credentials:MS-SP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6318 FALBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-9435
Mailing Address - Country:US
Mailing Address - Phone:904-318-3159
Mailing Address - Fax:904-396-2520
Practice Address - Street 1:3627 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 210
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4230
Practice Address - Country:US
Practice Address - Phone:904-399-5311
Practice Address - Fax:904-396-2520
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 574235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist