=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710196514
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA L. AMY MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31890 S GALENA DR
-----------------------------------------------------
City | MARANA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85653-8868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-419-6419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31890 S GALENA DR
-----------------------------------------------------
City | MARANA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85653-8868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-419-6419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 0037
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------