Healthcare Provider Details

I. General information

NPI: 1679838205
Provider Name (Legal Business Name): AMANDA JEAN STRUCKMEYER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA JEAN HEISELE MHS, CCC-SLP

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12380 DE PAUL DR SSM DAY INSTITUTE
BRIDGETON MO
63044-2511
US

IV. Provider business mailing address

12380 DE PAUL DR SSM DAY INSTITUTE
BRIDGETON MO
63044-2511
US

V. Phone/Fax

Practice location:
  • Phone: 314-447-9710
  • Fax:
Mailing address:
  • Phone: 314-447-9710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2011032948
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: