Provider Demographics
NPI:1104129089
Name:AMA, LAIS (LICENSED HAD)
Entity type:Individual
Prefix:
First Name:LAIS
Middle Name:
Last Name:AMA
Suffix:
Gender:F
Credentials:LICENSED HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 N SAN MATEO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2824
Mailing Address - Country:US
Mailing Address - Phone:650-342-9449
Mailing Address - Fax:
Practice Address - Street 1:88 N. SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94070
Practice Address - Country:US
Practice Address - Phone:650-342-9449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA7626237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist