Provider Demographics
NPI:1124750211
Name:MARTIN, AMANDA JUNE (SLPA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JUNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 S VAL VISTA DR STE 190
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1674
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2680 S VAL VISTA DR STE 190
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1674
Practice Address - Country:US
Practice Address - Phone:602-345-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA138912355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant