Provider Demographics
NPI:1154099505
Name:GESOURAS, AMANDA (MA CF-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GESOURAS
Suffix:
Gender:F
Credentials:MA CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3474 E LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-2219
Mailing Address - Country:US
Mailing Address - Phone:614-324-4585
Mailing Address - Fax:
Practice Address - Street 1:3474 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-2219
Practice Address - Country:US
Practice Address - Phone:614-324-4585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.20211778-SP235Z00000X
OHSP.14925235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist