Provider Demographics
NPI:1275811242
Name:FRY, AMELIA (MS, CCC-SLP, IBCLC)
Entity Type:Individual
Prefix:MS
First Name:AMELIA
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:MS, CCC-SLP, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SE HIBISCUS AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34996-3602
Mailing Address - Country:US
Mailing Address - Phone:772-485-4357
Mailing Address - Fax:772-872-5858
Practice Address - Street 1:615 SE HIBISCUS AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3602
Practice Address - Country:US
Practice Address - Phone:772-485-4357
Practice Address - Fax:772-872-5858
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174N00000X, 235Z00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
L-111185OtherINTERNATIONAL BOARD OF LACTATION CONSULTANT EXAMINERS
FL004024000Medicaid
14030798OtherAMERICAN SPEECH AND HEARING ASSOCIATION