Provider Demographics
NPI:1346888435
Name:AMY AMANDA PRUSAK
Entity Type:Organization
Organization Name:AMY AMANDA PRUSAK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:AMANDA
Authorized Official - Last Name:PRUSAK
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:630-336-5213
Mailing Address - Street 1:14341 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-2430
Mailing Address - Country:US
Mailing Address - Phone:312-725-6148
Mailing Address - Fax:
Practice Address - Street 1:17500 DUVAN DR STE 2B
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3671
Practice Address - Country:US
Practice Address - Phone:708-400-8348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty