Provider Demographics
NPI:1578964888
Name:WALLACE, AMANDA LEIGH (MA CF-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LEIGH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CAROLINA DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-3616
Mailing Address - Country:US
Mailing Address - Phone:419-270-0041
Mailing Address - Fax:
Practice Address - Street 1:928 W MARKET ST
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2529
Practice Address - Country:US
Practice Address - Phone:419-270-0041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-07
Last Update Date:2014-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND. 2014271235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist