Provider Demographics
NPI:1891123360
Name:AGUAYO, AMY ALICIA (MED,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ALICIA
Last Name:AGUAYO
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 PEACHTREE RD STE C120
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30360-3234
Mailing Address - Country:US
Mailing Address - Phone:678-514-3270
Mailing Address - Fax:
Practice Address - Street 1:6035 PEACHTREE RD STE C120
Practice Address - Street 2:
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30360-3234
Practice Address - Country:US
Practice Address - Phone:678-514-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-21
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003139764AMedicaid