Healthcare Provider Details

I. General information

NPI: 1992166276
Provider Name (Legal Business Name): AMANDA WAIT B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

IV. Provider business mailing address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

V. Phone/Fax

Practice location:
  • Phone: 309-820-3651
  • Fax: 309-820-3745
Mailing address:
  • Phone: 309-820-3651
  • Fax: 309-820-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: