Basic Information
| Provider Information | |||||||||
| NPI: | 1831265123 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | AMY | ||||||||
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| Credential: | M.ED.,CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 CHARLOIS BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367250222 | ||||||||
| FaxNumber: | 3367250454 | ||||||||
| Practice Location | |||||||||
| Address1: | 185 CHARLOIS BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367250222 | ||||||||
| FaxNumber: | 3367250454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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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 | SLP004977 | GA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 7640 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 305494 | 05 | GA | MEDICAID | 52868995-001 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 10035709 | 05 | GA | MEDICAID |