Provider Demographics
NPI:1164625547
Name:TREZEK, AMY S
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:TREZEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 BIG CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MOSCOW MILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63362-1940
Mailing Address - Country:US
Mailing Address - Phone:636-734-7564
Mailing Address - Fax:
Practice Address - Street 1:67 BIG CREEK DR
Practice Address - Street 2:
Practice Address - City:MOSCOW MILLS
Practice Address - State:MO
Practice Address - Zip Code:63362-1940
Practice Address - Country:US
Practice Address - Phone:636-734-7564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0329665235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO467446407Medicaid