Provider Demographics
NPI:1174860126
Name:BROSELL, AMANDA (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:BROSELL
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 1:4654 WADE ST APT 101
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-2209
Mailing Address - Country:US
Mailing Address - Phone:360-715-3084
Mailing Address - Fax:
Practice Address - Street 1:124 E LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2914
Practice Address - Country:US
Practice Address - Phone:360-428-6122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60327212235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist