Provider Demographics
NPI:1306148846
Name:BENNETT, AMY DIANNE (SLP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:DIANNE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-2149
Mailing Address - Country:US
Mailing Address - Phone:806-679-5852
Mailing Address - Fax:
Practice Address - Street 1:1535 TIGER CIR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-4300
Practice Address - Country:US
Practice Address - Phone:575-445-3541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2438235Z00000X
NMC-4803235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist