Provider Demographics
NPI:1366005365
Name:OTTO, AMANDA S
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:OTTO
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 1:9630 CHANDON DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-6131
Mailing Address - Country:US
Mailing Address - Phone:727-249-9605
Mailing Address - Fax:
Practice Address - Street 1:7203 ALOMA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-7101
Practice Address - Country:US
Practice Address - Phone:321-972-3960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0700X
FLSA17890235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech