Provider Demographics
NPI:1205075561
Name:HARTY, AMANDA NICOLE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:HARTY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:MANDI
Other - Middle Name:
Other - Last Name:KEELER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:611 WHITE LICK LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-1274
Mailing Address - Country:US
Mailing Address - Phone:317-340-4764
Mailing Address - Fax:
Practice Address - Street 1:611 WHITE LICK LANE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168
Practice Address - Country:US
Practice Address - Phone:317-340-4764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-10
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12146018235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist