Provider Demographics
NPI:1487741930
Name:LONGWELL, AMANDA BETH (MS CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:BETH
Last Name:LONGWELL
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 MORGANTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-4513
Mailing Address - Country:US
Mailing Address - Phone:304-366-8498
Mailing Address - Fax:
Practice Address - Street 1:230 GRANDE MDWS
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9711
Practice Address - Country:US
Practice Address - Phone:304-592-2009
Practice Address - Fax:304-592-2004
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0901235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7402351-000Medicaid