Provider Demographics
NPI:1316182249
Name:LEE, AMANDA W
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:W
Last Name:LEE
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 1:9565 HIGHWAY 78
Mailing Address - Street 2:BUILDING 700 SUITE 102
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4118
Mailing Address - Country:US
Mailing Address - Phone:888-510-6369
Mailing Address - Fax:888-510-9156
Practice Address - Street 1:9565 HIGHWAY 78
Practice Address - Street 2:BUILDING 700 SUITE 102
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456
Practice Address - Country:US
Practice Address - Phone:888-510-6369
Practice Address - Fax:888-510-9156
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3759235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0944Medicaid
SC3754OtherSPEECH-LANGUAGE PATHOLOGIST