Provider Demographics
NPI:1639307929
Name:LANGE, AMANDA (SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 SHERATON AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-2044
Mailing Address - Country:US
Mailing Address - Phone:979-885-9785
Mailing Address - Fax:
Practice Address - Street 1:1611 HEADWAY CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-5160
Practice Address - Country:US
Practice Address - Phone:512-615-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104483235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist