Provider Demographics
NPI:1053705129
Name:HERBERT, AMY RENAE (CCC, SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:RENAE
Last Name:HERBERT
Suffix:
Gender:F
Credentials:CCC, SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:RENAE
Other - Last Name:HERBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6017 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-2648
Mailing Address - Country:US
Mailing Address - Phone:228-697-2269
Mailing Address - Fax:
Practice Address - Street 1:6017 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-2648
Practice Address - Country:US
Practice Address - Phone:228-697-2269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL14109551OtherASHA CERTIFICATION