Basic Information
Provider Information | |||||||||
NPI: | 1669622346 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAMAZE | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S. CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BAMAZE | ||||||||
OtherFirstName: | CINDY | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.S. CCC-SLP | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 15510 CAMDEN AVE | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681168450 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023204108 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10300 W 103RD ST STE 300 | ||||||||
Address2: | QUANTUM HEALTH PROFESSIONALS | ||||||||
City: | OVERLAND PARK | ||||||||
State: | KS | ||||||||
PostalCode: | 66214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9138941910 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2008 | ||||||||
LastUpdateDate: | 09/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235500000X | 09147436 | NE | N |   | Speech, Language and Hearing Service Providers | Specialist/Technologist |   | 235500000X | 1131 | NE | Y |   | Speech, Language and Hearing Service Providers | Specialist/Technologist |   |
ID Information
ID | Type | State | Issuer | Description | 1131 | 01 | NE | STATE LICENSE | OTHER |