Provider Demographics
NPI:1851800585
Name:VANDERWAAL, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VANDERWAAL
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 1:3945 WEHRMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SCHILLER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61073
Mailing Address - Country:US
Mailing Address - Phone:847-671-0250
Mailing Address - Fax:
Practice Address - Street 1:3945 WEHRMAN AVE
Practice Address - Street 2:
Practice Address - City:SCHILLER PARK
Practice Address - State:IL
Practice Address - Zip Code:60176-1814
Practice Address - Country:US
Practice Address - Phone:847-671-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1089074103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool