Basic Information
| Provider Information | |||||||||
| NPI: | 1003013590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATHIS | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | RUTH | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S. CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1186 HALE SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420254713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702520203 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 867 MCGUIRE AVE | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420014036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704426168 | ||||||||
| FaxNumber: | 2704436211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3125 | KY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 12501490 | 05 | KY | MEDICAID |