Provider Demographics
NPI:1598049421
Name:BANNISTER, AMANDA MARIE (MA, LIC/CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:MA, LIC/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8162 AVOSS LN
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-8965
Mailing Address - Country:US
Mailing Address - Phone:315-593-5570
Mailing Address - Fax:
Practice Address - Street 1:2592 STATE ROUTE 3
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-4852
Practice Address - Country:US
Practice Address - Phone:315-593-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020261-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist