Provider Demographics
NPI:1205336336
Name:BENES, AMANDA CELESTE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:CELESTE
Last Name:BENES
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 BROOK DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3911
Mailing Address - Country:US
Mailing Address - Phone:330-696-7802
Mailing Address - Fax:
Practice Address - Street 1:1777 NORTHEAST EXPY NE STE 120
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2475
Practice Address - Country:US
Practice Address - Phone:404-228-8558
Practice Address - Fax:855-242-2110
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009540235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581990269Medicaid