Provider Demographics
NPI:1285929380
Name:BRACKEN, AMANDA M (AUD, CCC-A)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W NIFONG BLVD
Mailing Address - Street 2:BUILDING 3, SUITE 100
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5615
Mailing Address - Country:US
Mailing Address - Phone:573-214-2000
Mailing Address - Fax:573-214-2042
Practice Address - Street 1:1000 W NIFONG BLVD
Practice Address - Street 2:BUILDING 3, SUITE 100
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5615
Practice Address - Country:US
Practice Address - Phone:573-214-2000
Practice Address - Fax:573-214-2042
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011017513231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2011017513OtherLICENSE ISSUED BY THE STATE OF MISSOURI