Healthcare Provider Details

I. General information

NPI: 1659937209
Provider Name (Legal Business Name): AMANDA JANE HALE MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2019
Last Update Date: 05/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043 BROOKLYN BLVD
BEREA KY
40403-1090
US

IV. Provider business mailing address

1008 BURNELL DR
BEREA KY
40403-9040
US

V. Phone/Fax

Practice location:
  • Phone: 859-228-0551
  • Fax:
Mailing address:
  • Phone: 859-582-3975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLPLPA00225539
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: