Provider Demographics
NPI:1376839241
Name:WEISS, AMANDA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WEISS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 STONEBLUFF CT
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-2408
Mailing Address - Country:US
Mailing Address - Phone:708-228-6629
Mailing Address - Fax:
Practice Address - Street 1:1505 STONEBLUFF CT
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-2408
Practice Address - Country:US
Practice Address - Phone:708-228-6629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009898235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist