Healthcare Provider Details

I. General information

NPI: 1740401579
Provider Name (Legal Business Name): AMY MATHENY CHURILLA M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 GOLDEN FERN COURT
ELKRIDGE MD
21044
US

IV. Provider business mailing address

4962 REEDY BROOK LN
COLUMBIA MD
21044-1514
US

V. Phone/Fax

Practice location:
  • Phone: 410-796-8499
  • Fax: 443-270-8260
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number18323
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: