Provider Demographics
NPI:1497112197
Name:TALLEY, AMANDA JOHNSTON (MCD, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JOHNSTON
Last Name:TALLEY
Suffix:
Gender:F
Credentials:MCD, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 PLAYERS CROSSING WAY
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5534
Mailing Address - Country:US
Mailing Address - Phone:270-779-7131
Mailing Address - Fax:
Practice Address - Street 1:300 WESTWOOD ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1030
Practice Address - Country:US
Practice Address - Phone:270-779-7131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2646235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist