Healthcare Provider Details

I. General information

NPI: 1215285457
Provider Name (Legal Business Name): AMANDA BROOKE MULLIGAN SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2012
Last Update Date: 08/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 PROFESSIONAL CT
LAFAYETTE IN
47905-5152
US

IV. Provider business mailing address

80 PROFESSIONAL CT
LAFAYETTE IN
47905-5152
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-1758
  • Fax: 765-448-3898
Mailing address:
  • Phone: 765-448-1758
  • Fax: 765-448-3898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number46002363A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: