Provider Demographics
NPI:1760694574
Name:DEROY, AMANDA (SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DEROY
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 1:470 S HILL ST
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3220
Mailing Address - Country:US
Mailing Address - Phone:678-482-6100
Mailing Address - Fax:770-932-5684
Practice Address - Street 1:470 S HILL ST
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3220
Practice Address - Country:US
Practice Address - Phone:678-482-6100
Practice Address - Fax:770-932-5684
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004505235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP004505OtherSPEECH THERAPY LICENSE