MEDICARE: AMANDA ENSTROM M.A., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	9382	MN

General Provider Information

NPI Number	:	1093119786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA ENSTROM M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	3464 WASHINGTON DR
Second Line	:	SUITE 110
City	:	EAGAN
State	:	MN
Zip	:	55122-1453
Country	:	US
Telephone Number	:	952-460-4278
Fax Number	:

Provider Business Practice Location Address
First Line	:	3464 WASHINGTON DR
Second Line	:	SUITE 110
City	:	EAGAN
State	:	MN
Zip	:	55122-1453
Country	:	US
Telephone Number	:	952-460-4278
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2014
Last Update Date	:	07/27/2016

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