Provider Demographics
NPI:1457361990
Name:ANDERSON, AMANDA LYNN (ATC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LAKEMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60051-8774
Mailing Address - Country:US
Mailing Address - Phone:847-486-4627
Mailing Address - Fax:847-486-5702
Practice Address - Street 1:4000 W LAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1239
Practice Address - Country:US
Practice Address - Phone:847-486-4627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0019712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer