Provider Demographics
NPI:1619036969
Name:LAFAVE, AMY ANN (MS CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:ANN
Last Name:LAFAVE
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:ANN
Other - Last Name:JANICSEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:1129 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304
Mailing Address - Country:US
Mailing Address - Phone:920-490-4677
Mailing Address - Fax:920-592-9320
Practice Address - Street 1:926 WILLARD DR
Practice Address - Street 2:SUITE 114
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304
Practice Address - Country:US
Practice Address - Phone:920-592-9330
Practice Address - Fax:920-592-9320
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1635154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42754500Medicaid