Provider Demographics
NPI:1700256641
Name:AUGUSTINE, AMY R
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5105
Mailing Address - Country:US
Mailing Address - Phone:573-335-1867
Mailing Address - Fax:573-334-2817
Practice Address - Street 1:301 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5105
Practice Address - Country:US
Practice Address - Phone:573-335-1867
Practice Address - Fax:573-334-2817
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015028032235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist