Provider Demographics
NPI:1568761187
Name:VAN DINE, AMY MELISSA (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MELISSA
Last Name:VAN DINE
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 1:635 GEORGES LN
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-1905
Mailing Address - Country:US
Mailing Address - Phone:484-412-8118
Mailing Address - Fax:
Practice Address - Street 1:635 GEORGES LN
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-1905
Practice Address - Country:US
Practice Address - Phone:484-412-8118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist