Provider Demographics
NPI:1508069337
Name:BRILL, AMANDA COFFMAN (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:COFFMAN
Last Name:BRILL
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:PO BOX 471
Mailing Address - Street 2:
Mailing Address - City:WARDENSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26851
Mailing Address - Country:US
Mailing Address - Phone:540-560-2553
Mailing Address - Fax:
Practice Address - Street 1:1840 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22604
Practice Address - Country:US
Practice Address - Phone:540-536-1126
Practice Address - Fax:540-536-5139
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005059235Z00000X
WVSLP-1095235Z00000X
12100992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009984Medicaid
12100992OtherASHA CCC
VA2202005059OtherSTATE SLP LICENSE
WVSLP-1095OtherSTATE SLP LICENSE