Provider Demographics
NPI:1578784526
Name:STANLEY, AMY NICOLE (MS CCC SLP L)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:NICOLE
Last Name:STANLEY
Suffix:
Gender:F
Credentials:MS CCC SLP L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 BELMONT PT
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-3506
Mailing Address - Country:US
Mailing Address - Phone:217-366-0033
Mailing Address - Fax:
Practice Address - Street 1:4102 BELMONT PT
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-3506
Practice Address - Country:US
Practice Address - Phone:217-366-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0146005506235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist