Provider Demographics
NPI:1588335582
Name:AVALOS, AMANDA (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:AVALOS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3644 S FORT APACHE RD APT 2063
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-3416
Mailing Address - Country:US
Mailing Address - Phone:440-506-5127
Mailing Address - Fax:
Practice Address - Street 1:1775 VILLAGE CENTER CIR STE 190
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-0571
Practice Address - Country:US
Practice Address - Phone:702-463-5460
Practice Address - Fax:888-316-4826
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.12332235Z00000X
NVSP-3100235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist