Provider Demographics
NPI:1366880155
Name:LIST, AMANDA (DT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:LIST
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10548 S SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3829
Mailing Address - Country:US
Mailing Address - Phone:708-990-2988
Mailing Address - Fax:815-531-0043
Practice Address - Street 1:25632 BARROW RD
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:IL
Practice Address - Zip Code:60442-6250
Practice Address - Country:US
Practice Address - Phone:773-544-9928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist