| Doctor Name: | AMANDA WALLACE |
| NPI Number: | 1053725952 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 242.003032 |
| Business Practice Address: | 40w310 Lafox Rd Suite A1/b1 St Charles, IL - 601756588 |
| Business Phone Number: | 6304440077 |
| Business Fax Number: | |
| Mailing Address: | 12 Harrison St, Apt 3 OAK PARK |
| State: | IL |
| Postal Code: | 603041771 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 06/18/2014 |
| NPI Last Update Date: | 06/18/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | 242.003032 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |