Provider Demographics
NPI:1316190374
Name:DIETZ, AMANDA S (MS-CCC, SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:DIETZ
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 1:10 BELLMORE PL.
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137
Mailing Address - Country:US
Mailing Address - Phone:386-627-0632
Mailing Address - Fax:
Practice Address - Street 1:10 BELLMORE PL.
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137
Practice Address - Country:US
Practice Address - Phone:386-627-0632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8518235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist