Provider Demographics
NPI:1295217099
Name:WEATHERLY, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WEATHERLY
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 1:101 SUMMIT AVE STE 510
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-2613
Mailing Address - Country:US
Mailing Address - Phone:682-730-0004
Mailing Address - Fax:
Practice Address - Street 1:101 SUMMIT AVE STE 510
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-2613
Practice Address - Country:US
Practice Address - Phone:682-730-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10071235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist