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NPI Code Detail

MEDICARE: AMANDA VAN STADEN M.S., CCC-SLP

MEDICARE: AMANDA VAN STADEN M.S., 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
1235Z00000XSpeech-Language Pathologist
2235Z00000XSpeech-Language PathologistSLP009103GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
114113603OTHERASHA

General Provider Information

NPI Number : 1093173825
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMANDA VAN STADEN M.S., CCC-SLP
Provider Business Mailing Address
First Line : 1230 JOHNSON FERRY PL STE G10
Second Line :
City : MARIETTA
State : GA
Zip : 30068-2045
Country : US
Telephone Number : 770-321-6705
Fax Number :
Provider Business Practice Location Address
First Line : 1230 JOHNSON FERRY PL STE G10
Second Line :
City : MARIETTA
State : GA
Zip : 30068-2045
Country : US
Telephone Number : 770-321-6705
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/08/2016
Last Update Date : 09/08/2020

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Directions to “ AMANDA VAN STADEN M.S., CCC-SLP” Practice Location

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