Provider Demographics
NPI:1104104678
Name:WYDEVELD, AMANDA BETH (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:BETH
Last Name:WYDEVELD
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 1:12550 AURORA AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8036
Mailing Address - Country:US
Mailing Address - Phone:206-826-1097
Mailing Address - Fax:206-826-1179
Practice Address - Street 1:12550 AURORA AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8036
Practice Address - Country:US
Practice Address - Phone:206-363-7303
Practice Address - Fax:206-826-1179
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60233622235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist