Provider Demographics
NPI:1740954874
Name:WHITAKER, AMANDA ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ANN
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2446
Mailing Address - Street 2:
Mailing Address - City:RUNNING SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92382-2446
Mailing Address - Country:US
Mailing Address - Phone:909-672-0969
Mailing Address - Fax:
Practice Address - Street 1:29099 HOSPITAL RD
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352
Practice Address - Country:US
Practice Address - Phone:909-337-0844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist