Provider Demographics
NPI:1972664472
Name:NUSSINOW, AMY (SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:NUSSINOW
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 STRAWBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5952
Mailing Address - Country:US
Mailing Address - Phone:207-782-2150
Mailing Address - Fax:207-782-3621
Practice Address - Street 1:918 SABATTUS STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-782-1680
Practice Address - Fax:207-782-2534
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP535235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME297810099Medicaid