Provider Demographics
NPI:1962022400
Name:MITCHELL, AMY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:GALLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:937 RIO GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4348
Mailing Address - Country:US
Mailing Address - Phone:707-446-4460
Mailing Address - Fax:
Practice Address - Street 1:937 RIO GRANDE DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-4348
Practice Address - Country:US
Practice Address - Phone:707-446-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP12700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist