Provider Demographics
NPI:1699488916
Name:GRIGLACK, AMANDA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GRIGLACK
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 1:26 FAIRMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-6447
Mailing Address - Country:US
Mailing Address - Phone:504-905-1528
Mailing Address - Fax:
Practice Address - Street 1:17 WATCHUNG PLZ
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4117
Practice Address - Country:US
Practice Address - Phone:973-744-0804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01176800235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist