Provider Demographics
NPI:1568724805
Name:SQUIRES, AMY T (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:T
Last Name:SQUIRES
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 1:200 ATLANTA PROVIDENCE CT
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004-7523
Mailing Address - Country:US
Mailing Address - Phone:678-824-2145
Mailing Address - Fax:
Practice Address - Street 1:200 ATLANTA PROVIDENCE CT
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:GA
Practice Address - Zip Code:30004-7523
Practice Address - Country:US
Practice Address - Phone:678-824-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008235235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist