1144392861 NPI number — AMY SHANDY SPEECH LANGUAGE PATHOLOGIST

Table of content: (NPI 1144392861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144392861 NPI number — AMY SHANDY SPEECH LANGUAGE PATHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMY SHANDY SPEECH LANGUAGE PATHOLOGIST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE SHANDY CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144392861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8540 SCARBOROUGH DRIVE
Provider Second Line Business Mailing Address:
SUITE 290
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-597-0822
Provider Business Mailing Address Fax Number:
719-599-4606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8540 SCARBOROUGH DRIVE
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-597-0822
Provider Business Practice Location Address Fax Number:
719-599-4606
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NEWMAN
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
719-597-0822

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 09122115 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 20051321398 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 28678737 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12000256 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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