Provider Demographics
NPI:1578827853
Name:BOTHA, AMANDA JANE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JANE
Last Name:BOTHA
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 1:602 MARINER BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34949-3602
Mailing Address - Country:US
Mailing Address - Phone:954-439-6043
Mailing Address - Fax:
Practice Address - Street 1:602 MARINER BAY BLVD
Practice Address - Street 2:
Practice Address - City:HUTCHINSON ISLAND
Practice Address - State:FL
Practice Address - Zip Code:34949-3602
Practice Address - Country:US
Practice Address - Phone:954-439-6043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12524235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013297100Medicaid