Provider Demographics
NPI:1689197071
Name:CHILDERS, AMANDA (SLP ASSISTANT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:SLP ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NE LOOP 820 BUSINESS TOWER 1
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:14515 BRIARHILLS PKWY STE 208
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-1034
Practice Address - Country:US
Practice Address - Phone:713-575-2000
Practice Address - Fax:713-575-2031
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX350492355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23Medicaid