Basic Information
| Provider Information | |||||||||
| NPI: | 1356648745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHIPPLE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | |||||||||
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| OtherOrganizationType: | |||||||||
| OtherLastName: | FARRAND | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 149 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144501434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853772230 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 149 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | FAIRPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853346000 | ||||||||
| FaxNumber: | 5853342858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2011 | ||||||||
| LastUpdateDate: | 06/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 0207431 | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 00355344 | 05 | NY | MEDICAID |