Provider Demographics
NPI:1508068412
Name:GOMEZ, AMANDA P (MS-CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:P
Last Name:GOMEZ
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 1:4530 NELSON BROGDON BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-5407
Mailing Address - Country:US
Mailing Address - Phone:678-820-9606
Mailing Address - Fax:844-820-9616
Practice Address - Street 1:4530 NELSON BROGDON BLVD STE C
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518
Practice Address - Country:US
Practice Address - Phone:678-820-9606
Practice Address - Fax:844-820-9616
Is Sole Proprietor?:No
Enumeration Date:2007-06-03
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006456235Z00000X
GASLP 006456235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134692AMedicaid
GA198576913DMedicaid