Provider Demographics
NPI:1528571296
Name:AMPHD THERAPEUTIC CONNECTIONS
Entity Type:Organization
Organization Name:AMPHD THERAPEUTIC CONNECTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:225-278-8919
Mailing Address - Street 1:37406 PROVENCE POINTE AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4397
Mailing Address - Country:US
Mailing Address - Phone:225-278-8919
Mailing Address - Fax:
Practice Address - Street 1:16172 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-4212
Practice Address - Country:US
Practice Address - Phone:225-278-8919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3013261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1300071Medicaid