Provider Demographics
NPI:1073904546
Name:BEAVER, AMANDA YVONNE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:YVONNE
Last Name:BEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4355 STATE HIGHWAY 148
Mailing Address - Street 2:
Mailing Address - City:MULKEYTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62865-3219
Mailing Address - Country:US
Mailing Address - Phone:618-927-2647
Mailing Address - Fax:
Practice Address - Street 1:306 W MILL ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2727
Practice Address - Country:US
Practice Address - Phone:618-529-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.012424235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist