Provider Demographics
NPI:1356411730
Name:PIERSON, AMY (SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PIERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:SOUTHERLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, CCC-SLP
Mailing Address - Street 1:3358 INDIAN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8728
Mailing Address - Country:US
Mailing Address - Phone:850-994-8424
Mailing Address - Fax:
Practice Address - Street 1:5165 CANAL ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-2256
Practice Address - Country:US
Practice Address - Phone:850-623-4054
Practice Address - Fax:850-623-4987
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005163235Z00000X
FLSA 8838235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005163OtherLICENSE NUMBER
FLSA8838OtherSLP STATE LICENSE