Provider Demographics
NPI:1710173455
Name:WORDEN, AMANDA S (SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:WORDEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:SOPRANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:68 S MAIN ST
Mailing Address - Street 2:PO BOX 1188
Mailing Address - City:MORAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13118-2310
Mailing Address - Country:US
Mailing Address - Phone:315-497-2670
Mailing Address - Fax:315-497-3961
Practice Address - Street 1:24 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MORAVIA
Practice Address - State:NY
Practice Address - Zip Code:13118-2307
Practice Address - Country:US
Practice Address - Phone:315-497-2670
Practice Address - Fax:315-497-3961
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY018312-1OtherSLP LICENSE NUMBER
NY16903813OtherNYS TEACHER CERTIFICATE