Provider Demographics
NPI:1477936276
Name:MILLEVILLE, AMANDA A (SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:A
Last Name:MILLEVILLE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:THALHAMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:74 YANK ST
Mailing Address - Street 2:
Mailing Address - City:COURTDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18704-1136
Mailing Address - Country:US
Mailing Address - Phone:317-726-7534
Mailing Address - Fax:
Practice Address - Street 1:74 YANK ST
Practice Address - Street 2:
Practice Address - City:COURTDALE
Practice Address - State:PA
Practice Address - Zip Code:18704-1136
Practice Address - Country:US
Practice Address - Phone:317-726-7534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110147235Z00000X
PASL013139235Z00000X
GASLP009023235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist