Provider Demographics
NPI:1669609061
Name:PACKER, AMY THERESE (AUD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:THERESE
Last Name:PACKER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:COUNIHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8800 SE SUNNYSIDE RD.
Mailing Address - Street 2:STE. 300-N
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5738
Mailing Address - Country:US
Mailing Address - Phone:503-659-5115
Mailing Address - Fax:218-724-3539
Practice Address - Street 1:2522 MAPLE GROVE RD.
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811
Practice Address - Country:US
Practice Address - Phone:218-727-2333
Practice Address - Fax:218-724-3539
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5706231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist