Healthcare Provider Details

I. General information

NPI: 1326710195
Provider Name (Legal Business Name): AMANDA J REDEKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E MAIN ST
HART MI
49420-1168
US

IV. Provider business mailing address

701 E MAIN ST
HART MI
49420-1168
US

V. Phone/Fax

Practice location:
  • Phone: 231-873-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7152000182
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: