MEDICARE: AMY SHANDY, SPEECH-LANGUAGE PATHOLOGIST, LLC

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
2	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1225665219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMY SHANDY, SPEECH-LANGUAGE PATHOLOGIST, LLC

Provider Business Mailing Address
First Line	:	3625 CITADEL DR S
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-5320
Country	:	US
Telephone Number	:	719-597-0822
Fax Number	:	719-599-4606

Provider Business Practice Location Address
First Line	:	MOUNTAIN VIEW CORE KNOWLEDGE SCHOOL
Second Line	:	890 FIELD AVE
City	:	CANNON CITY
State	:	CO
Zip	:	81212-9250
Country	:	US
Telephone Number	:	719-597-0822
Fax Number	:	719-599-4606

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	REBECCA NEWMAN
Credential	:
Telephone Number	:	719-597-0822

Provider Enumeration Date	:	03/27/2020
Last Update Date	:	03/27/2020

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