Provider Demographics
NPI:1790188522
Name:MAXWELL, AMANDA GAYLE (MS CF-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GAYLE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5067 SHADY REST RD
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-4929
Mailing Address - Country:US
Mailing Address - Phone:850-556-9897
Mailing Address - Fax:
Practice Address - Street 1:1725 HERMITAGE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-7709
Practice Address - Country:US
Practice Address - Phone:850-325-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6875235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist