Provider Demographics
NPI:1316457146
Name:EAGLES, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:EAGLES
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 1:4851 BLUESTEM DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-1349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10850 E WOODMEN RD
Practice Address - Street 2:
Practice Address - City:PEYTON
Practice Address - State:CO
Practice Address - Zip Code:80831-8127
Practice Address - Country:US
Practice Address - Phone:719-495-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NHP-0806235Z00000X
CO235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst