Healthcare Provider Details

I. General information

NPI: 1407502982
Provider Name (Legal Business Name): AMY WHELAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 S FITNESS PL
EAGLE ID
83616-6828
US

IV. Provider business mailing address

6826 W MCMULLEN ST
BOISE ID
83709-1954
US

V. Phone/Fax

Practice location:
  • Phone: 208-957-6301
  • Fax: 208-228-0585
Mailing address:
  • Phone: 602-510-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP-2533
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: