MEDICARE: MISS AMANDA LEIGH WINGERTSAHN SP

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	2004034552	MO

General Provider Information

NPI Number	:	1669445953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS AMANDA LEIGH WINGERTSAHN SP

Provider Business Mailing Address
First Line	:	1177 N. WARSON RD
Second Line	:
City	:	ST. LOUIS
State	:	MO
Zip	:	63132
Country	:	US
Telephone Number	:	314-569-2211
Fax Number	:	314-569-0778

Provider Business Practice Location Address
First Line	:	1177 N. WARSON RD
Second Line	:
City	:	ST. LOUIS
State	:	MO
Zip	:	63132
Country	:	US
Telephone Number	:	314-569-2211
Fax Number	:	314-569-0778

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

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	01/13/2015

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