Provider Demographics
NPI:1518286087
Name:VELASQUEZ, AMANDA M (AUD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:AUD
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 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-4871
Mailing Address - Fax:682-885-3639
Practice Address - Street 1:750 MID CITIES BLVD
Practice Address - Street 2:STE 110
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-2792
Practice Address - Country:US
Practice Address - Phone:817-581-2794
Practice Address - Fax:817-656-3659
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80305231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336198894OtherGROUP NPI NUMBER
TX021184901Medicaid