Provider Demographics
NPI:1023408911
Name:STALLWORTH, AMBER DAWN (AUD)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:DAWN
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12718 AZALEA CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-3207
Mailing Address - Country:US
Mailing Address - Phone:512-496-2362
Mailing Address - Fax:
Practice Address - Street 1:915 GESSNER RD
Practice Address - Street 2:SUITE 280
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-2527
Practice Address - Country:US
Practice Address - Phone:713-461-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX80737237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program