Provider Demographics
NPI:1457691743
Name:LEDERER, AMANDA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LEDERER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:469 W HURON ST
Mailing Address - Street 2:1010
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3467
Mailing Address - Country:US
Mailing Address - Phone:201-294-4929
Mailing Address - Fax:
Practice Address - Street 1:469 W HURON ST
Practice Address - Street 2:1010
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3467
Practice Address - Country:US
Practice Address - Phone:201-294-4929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242002115235Z00000X
IL145011896235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist