Provider Demographics
NPI:1720171689
Name:FOUTCH, AMANDA (CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:
Last Name:FOUTCH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4482 FORD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-9189
Mailing Address - Country:US
Mailing Address - Phone:954-540-4808
Mailing Address - Fax:888-232-1831
Practice Address - Street 1:4482 FORD AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-9189
Practice Address - Country:US
Practice Address - Phone:954-540-4808
Practice Address - Fax:888-232-1831
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6775235Z00000X
MI7101005581235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000206200Medicaid