Provider Demographics
NPI:1528501210
Name:BERMUDEZ, AMANDA LISA (MS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LISA
Last Name:BERMUDEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LISA
Other - Last Name:SEPULVEDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:3334 80TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-1341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3334 80TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-1341
Practice Address - Country:US
Practice Address - Phone:718-457-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58025300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist