Provider Demographics
NPI:1811009426
Name:KELLY, AMANDA WEATHERS (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:WEATHERS
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20880 SHARON DR
Mailing Address - Street 2:
Mailing Address - City:MC CALLA
Mailing Address - State:AL
Mailing Address - Zip Code:35111-1332
Mailing Address - Country:US
Mailing Address - Phone:205-218-0249
Mailing Address - Fax:
Practice Address - Street 1:120 OSLO CIR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-5965
Practice Address - Country:US
Practice Address - Phone:205-944-3980
Practice Address - Fax:205-944-3990
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2214235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51525706OtherBCBS NUMBER
AL890012710Medicaid