MEDICARE: AMANDA SHAFFSTALL MS 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	103338	TX

General Provider Information

NPI Number	:	1871821934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA SHAFFSTALL MS CCC/SLP

Provider Business Mailing Address
First Line	:	8524 OLMSTEAD TER
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-5313
Country	:	US
Telephone Number	:	940-395-3973
Fax Number	:

Provider Business Practice Location Address
First Line	:	8524 OLMSTEAD TER
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-5313
Country	:	US
Telephone Number	:	940-395-3973
Fax Number	:

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

Provider Enumeration Date	:	12/01/2009
Last Update Date	:	12/01/2009

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