Provider Demographics
NPI:1124499264
Name:MARTIN, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15873 COUNTY ROAD 472
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75706
Mailing Address - Country:US
Mailing Address - Phone:903-509-1313
Mailing Address - Fax:903-509-1383
Practice Address - Street 1:2808 S. MAIN ST. SUITE C
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771
Practice Address - Country:US
Practice Address - Phone:936-637-9195
Practice Address - Fax:903-881-6010
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103789235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist