=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750636684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY MARIE AU M. ED, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2012
-----------------------------------------------------
Last Update Date | 07/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 MAYNARD LN
-----------------------------------------------------
City | STRASBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22657-1111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-465-2629
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 164 OXBOW DR
-----------------------------------------------------
City | STRASBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22657-5271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-465-3786
-----------------------------------------------------
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 | 2202006571
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------