Provider Demographics
NPI:1063881209
Name:WIDMAN, AMANDA (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:WIDMAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:SHELDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:269 PORTLAND WAY S
Mailing Address - Street 2:
Mailing Address - City:GALION
Mailing Address - State:OH
Mailing Address - Zip Code:44833-2312
Mailing Address - Country:US
Mailing Address - Phone:419-468-0570
Mailing Address - Fax:
Practice Address - Street 1:269 PORTLAND WAY S
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833-2312
Practice Address - Country:US
Practice Address - Phone:419-468-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND. 2015268235Z00000X
OHSP.12156235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist