Provider Demographics
NPI:1518205459
Name:WESSON, AMANDA POOLE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:POOLE
Last Name:WESSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 HOLLY BERRY LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-2946
Mailing Address - Country:US
Mailing Address - Phone:919-673-0976
Mailing Address - Fax:
Practice Address - Street 1:116 HOLLY BERRY LN
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-2946
Practice Address - Country:US
Practice Address - Phone:919-673-0976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007903235Z00000X
NC9889235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist