Provider Demographics
NPI:1225373509
Name:CULLEN, AMY (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CULLEN
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 1:107 NEETLE CLOSE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7076
Mailing Address - Country:US
Mailing Address - Phone:678-993-5927
Mailing Address - Fax:
Practice Address - Street 1:107 NEETLE CLOSE DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7076
Practice Address - Country:US
Practice Address - Phone:678-993-5927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006631235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist