Provider Demographics
NPI:1013270081
Name:RUSSELL SCHMIDT, AMANDA BROOKE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BROOKE
Last Name:RUSSELL SCHMIDT
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NORMA LN
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-4520
Mailing Address - Country:US
Mailing Address - Phone:631-292-2658
Mailing Address - Fax:
Practice Address - Street 1:1 NORMA LN
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-4520
Practice Address - Country:US
Practice Address - Phone:631-292-2658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-24
Last Update Date:2012-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019074-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist