Provider Demographics
NPI:1245367176
Name:BACON, AMY L (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:L
Last Name:BACON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60601
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70596-0601
Mailing Address - Country:US
Mailing Address - Phone:337-344-5407
Mailing Address - Fax:337-273-2583
Practice Address - Street 1:316 UPLAND DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-6852
Practice Address - Country:US
Practice Address - Phone:337-344-5407
Practice Address - Fax:334-344-5407
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5135235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1472221Medicaid