MEDICARE: AMANDA AVALOS 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	SP.12332	OH
2	235Z00000X	Speech-Language Pathologist	SP-3100	NV

General Provider Information

NPI Number	:	1588335582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA AVALOS M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	3644 S FORT APACHE RD APT 2063
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-3416
Country	:	US
Telephone Number	:	440-506-5127
Fax Number	:

Provider Business Practice Location Address
First Line	:	1775 VILLAGE CENTER CIR STE 190
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-0571
Country	:	US
Telephone Number	:	702-463-5460
Fax Number	:	888-316-4826

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

Provider Enumeration Date	:	09/21/2021
Last Update Date	:	09/21/2021

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