Provider Demographics
NPI:1518003763
Name:AMUNDSON, MARTIN A (MS, CCC-A)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:A
Last Name:AMUNDSON
Suffix:
Gender:M
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 PARK AVE
Mailing Address - Street 2:BLDG. D
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-0611
Mailing Address - Country:US
Mailing Address - Phone:270-443-3651
Mailing Address - Fax:270-441-7119
Practice Address - Street 1:400 PARK AVE
Practice Address - Street 2:BLDG. D
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-0611
Practice Address - Country:US
Practice Address - Phone:270-443-3651
Practice Address - Fax:270-441-7119
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0072231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist