Healthcare Provider Details

I. General information

NPI: 1487309480
Provider Name (Legal Business Name): AMANDA CHRISTINE WOOD M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA CHRISTINE CARRASCO

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N PEARSON ST
GODLEY TX
76044-3738
US

IV. Provider business mailing address

6633 KATIE CORRAL DR
FORT WORTH TX
76126-5448
US

V. Phone/Fax

Practice location:
  • Phone: 817-592-4169
  • Fax:
Mailing address:
  • Phone: 956-455-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number111552
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: