Provider Demographics
NPI:1760746671
Name:GONZALEZ, AMANDA MICHELLE
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:MICHELLE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14121 SW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-5933
Mailing Address - Country:US
Mailing Address - Phone:954-579-2866
Mailing Address - Fax:
Practice Address - Street 1:14121 SW 17TH ST
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33325-5933
Practice Address - Country:US
Practice Address - Phone:954-579-2866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ5796235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist