Provider Demographics
NPI:1992163091
Name:ELIAS, AMANDA BLYTHE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:BLYTHE
Last Name:ELIAS
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 1:5939 NEW NATCHITOCHES RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-1218
Mailing Address - Country:US
Mailing Address - Phone:318-342-1371
Mailing Address - Fax:
Practice Address - Street 1:700 UNIVERSITY AVE
Practice Address - Street 2:SUGAR HALL 155C
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71209-9000
Practice Address - Country:US
Practice Address - Phone:318-342-1371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6294235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist