Provider Demographics
NPI:1619714227
Name:AMENDOLA, MYA GRACE
Entity type:Individual
Prefix:
First Name:MYA
Middle Name:GRACE
Last Name:AMENDOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22579 AMBER CT
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-5100
Mailing Address - Country:US
Mailing Address - Phone:815-592-1690
Mailing Address - Fax:
Practice Address - Street 1:1101 31ST ST STE 110
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5562
Practice Address - Country:US
Practice Address - Phone:630-929-0122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist