Provider Demographics
NPI:1548442049
Name:DIEDERICH, AMANDA (AUDIOLOGIST)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5574
Mailing Address - Country:US
Mailing Address - Phone:815-725-1191
Mailing Address - Fax:815-725-1248
Practice Address - Street 1:2201 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5574
Practice Address - Country:US
Practice Address - Phone:815-725-1191
Practice Address - Fax:815-725-1248
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001236231HA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner