Provider Demographics
NPI:1053886101
Name:ZACHARY, AMANDA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ZACHARY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5402 SAYLE ST APT 167
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-6323
Mailing Address - Country:US
Mailing Address - Phone:281-222-9575
Mailing Address - Fax:
Practice Address - Street 1:4400 WALNUT ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5586
Practice Address - Country:US
Practice Address - Phone:903-455-8729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111705235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist