Provider Demographics
NPI:1306191713
Name:SELDOMRIDGE, AMY (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:SELDOMRIDGE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:OLDHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4601 NE 77TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4601 NE 77TH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6729
Practice Address - Country:US
Practice Address - Phone:360-892-6628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014688-1235Z00000X
MT3099235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist