Provider Demographics
NPI:1942738869
Name:HOUSEMAN, AMANDA ANN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANN
Last Name:HOUSEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ANN
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:68 BRIDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-6143
Mailing Address - Country:US
Mailing Address - Phone:158-578-6763
Mailing Address - Fax:
Practice Address - Street 1:254 RED CEDAR ST STE 9
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-8967
Practice Address - Country:US
Practice Address - Phone:843-970-2899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6426235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA2018Medicaid