Provider Demographics
NPI:1649880311
Name:EIBELL, AMY L (MS, CCC-CLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:EIBELL
Suffix:
Gender:F
Credentials:MS, CCC-CLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5517 PORTOLA CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2642
Mailing Address - Country:US
Mailing Address - Phone:978-996-2295
Mailing Address - Fax:
Practice Address - Street 1:5517 PORTOLA CIR
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2642
Practice Address - Country:US
Practice Address - Phone:978-996-2295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18934235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist