Healthcare Provider Details

I. General information

NPI: 1528453958
Provider Name (Legal Business Name): AMANDA LEVENTHAL MCD CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 08/31/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 SAUTEE WOODS TRL
SAUTEE NACOOCHEE GA
30571-2506
US

IV. Provider business mailing address

PO BOX 1892
CARROLLTON GA
30112-0036
US

V. Phone/Fax

Practice location:
  • Phone: 470-309-4220
  • Fax:
Mailing address:
  • Phone: 470-309-4220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number008429
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: