Provider Demographics
NPI:1104641331
Name:WILSON, AMANDA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-1290 KEOPU MAUKA DR
Mailing Address - Street 2:
Mailing Address - City:HOLUALOA
Mailing Address - State:HI
Mailing Address - Zip Code:96725-9637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81-1080 KONAWAENA SCHOOL RD
Practice Address - Street 2:
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750-8188
Practice Address - Country:US
Practice Address - Phone:808-480-1086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HISP-2046235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist