Provider Demographics
NPI:1295127827
Name:WICHERT, AMANDA BROOKE (MA SLP-CCC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:BROOKE
Last Name:WICHERT
Suffix:
Gender:F
Credentials:MA SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3572 CANNONADE CT
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-4632
Mailing Address - Country:US
Mailing Address - Phone:405-762-9411
Mailing Address - Fax:
Practice Address - Street 1:3572 CANNONADE CT STE B
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-4632
Practice Address - Country:US
Practice Address - Phone:405-762-9411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4169235Z00000X
IN22006582A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200527550AMedicaid