Provider Demographics
NPI:1396892188
Name:BANDA, PAMELA M (MSCCCSLPL)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:M
Last Name:BANDA
Suffix:
Gender:F
Credentials:MSCCCSLPL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11767 WINDING TRAILS DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1619
Mailing Address - Country:US
Mailing Address - Phone:708-839-9947
Mailing Address - Fax:708-839-9947
Practice Address - Street 1:11767 WINDING TRAILS DRIVE
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60480-1619
Practice Address - Country:US
Practice Address - Phone:708-839-9947
Practice Address - Fax:708-839-9947
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146001363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1628161OtherBLUE CROSS PROVIDER ID