Provider Demographics
NPI:1932479011
Name:MCGUKIN, AMANDA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:MCGUKIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 TIMBER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7206
Mailing Address - Country:US
Mailing Address - Phone:949-468-9348
Mailing Address - Fax:
Practice Address - Street 1:515 TIMBER LAKE DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7206
Practice Address - Country:US
Practice Address - Phone:949-468-9348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107234235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287168301Medicaid
TX81S586OtherBCBS