=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992330096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMIE MANYGOATS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2020
-----------------------------------------------------
Last Update Date | 03/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31645 N ROYAL OAK WAY
-----------------------------------------------------
City | SAN TAN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85143-6341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-677-3349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4775 E HORSE MESA TRL
-----------------------------------------------------
City | SAN TAN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85140-7022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-250-1997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | SLPA12283
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------