Provider Demographics
NPI:1669657631
Name:ARAGON-GABALDON, AMANDA RENEE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:RENEE
Last Name:ARAGON-GABALDON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 CIMARRON CT
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-7076
Mailing Address - Country:US
Mailing Address - Phone:920-684-3191
Mailing Address - Fax:
Practice Address - Street 1:3315 CIMARRON CT
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-7076
Practice Address - Country:US
Practice Address - Phone:920-684-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2819-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42581300Medicaid