Provider Demographics
NPI:1023686532
Name:HAGGERTY, AMANDA BROOK
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:BROOK
Last Name:HAGGERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 PATRIOT DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2683
Mailing Address - Country:US
Mailing Address - Phone:573-275-8089
Mailing Address - Fax:
Practice Address - Street 1:518 OLD US 221 HWY
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-8670
Practice Address - Country:US
Practice Address - Phone:828-287-7655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-12
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1109Medicaid