Provider Demographics
NPI:1003013590
Name:LANE, AMANDA RUTH (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:RUTH
Last Name:LANE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:RUTH
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:1186 HALE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-4713
Mailing Address - Country:US
Mailing Address - Phone:270-252-0203
Mailing Address - Fax:
Practice Address - Street 1:867 MCGUIRE AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-4036
Practice Address - Country:US
Practice Address - Phone:270-442-6168
Practice Address - Fax:270-443-6211
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3125235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12501490Medicaid