Provider Demographics
NPI:1114132859
Name:DAVIS, AMANDA G (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:G
Last Name:DAVIS
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 1:4301 W MARKHAM ST, SLOT #621-1
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7199
Mailing Address - Country:US
Mailing Address - Phone:501-526-2286
Mailing Address - Fax:501-526-5005
Practice Address - Street 1:4301 W MARKHAM ST, SLOT #621-1
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7199
Practice Address - Country:US
Practice Address - Phone:501-526-2286
Practice Address - Fax:501-526-5005
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3221235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
515-30958OtherBLUE CROSS PROVIDER NUMBE