Provider Demographics
NPI:1093119786
Name:ENSTROM, AMANDA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ENSTROM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3464 WASHINGTON DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1453
Mailing Address - Country:US
Mailing Address - Phone:952-460-4278
Mailing Address - Fax:
Practice Address - Street 1:3464 WASHINGTON DR
Practice Address - Street 2:SUITE 110
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-1453
Practice Address - Country:US
Practice Address - Phone:952-460-4278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9382235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist