Provider Demographics
NPI:1053591446
Name:EGAN, AMY B (SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:B
Last Name:EGAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 FLORIDA AVE S
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2152
Mailing Address - Country:US
Mailing Address - Phone:321-634-3688
Mailing Address - Fax:321-504-0955
Practice Address - Street 1:1024 FLORIDA AVE S
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2152
Practice Address - Country:US
Practice Address - Phone:321-634-3688
Practice Address - Fax:321-504-0955
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7094235Z00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890245300Medicaid