Provider Demographics
NPI:1336247386
Name:DAVIS, AMANDA GAYLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GAYLE
Last Name:DAVIS
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 1:3860 PENDIENTE CT
Mailing Address - Street 2:#103
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3752
Mailing Address - Country:US
Mailing Address - Phone:619-302-2123
Mailing Address - Fax:
Practice Address - Street 1:11665 AVENA PL
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2421
Practice Address - Country:US
Practice Address - Phone:858-673-5437
Practice Address - Fax:858-673-5434
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 14593235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist