Provider Demographics
NPI:1619326717
Name:PORTRA, AMANDA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PORTRA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:SWOPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1511 SHARLOH LOOP APT B
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-7822
Mailing Address - Country:US
Mailing Address - Phone:701-751-6336
Mailing Address - Fax:701-751-6337
Practice Address - Street 1:4530 NORTHERN SKY DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-8534
Practice Address - Country:US
Practice Address - Phone:701-751-6336
Practice Address - Fax:701-751-6337
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1504235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist