Provider Demographics
NPI:1487123980
Name:BERTSCH, AMANDA DANIELLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DANIELLE
Last Name:BERTSCH
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 1:784 BLANDING BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7724
Mailing Address - Country:US
Mailing Address - Phone:904-264-2636
Mailing Address - Fax:904-517-1621
Practice Address - Street 1:784 BLANDING BLVD STE 108
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7724
Practice Address - Country:US
Practice Address - Phone:904-264-2636
Practice Address - Fax:904-517-1621
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16760235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist