MEDICARE: MRS. PAMELA M BANDA MSCCCSLPL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	146001363	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1628161	OTHER	IL	BLUE CROSS PROVIDER ID

General Provider Information

NPI Number	:	1396892188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAMELA M BANDA MSCCCSLPL

Provider Business Mailing Address
First Line	:	11767 WINDING TRAILS DRIVE
Second Line	:
City	:	WILLOW SPRINGS
State	:	IL
Zip	:	60480-1619
Country	:	US
Telephone Number	:	708-839-9947
Fax Number	:	708-839-9947

Provider Business Practice Location Address
First Line	:	11767 WINDING TRAILS DRIVE
Second Line	:
City	:	WILLOW SPRINGS
State	:	IL
Zip	:	60480-1619
Country	:	US
Telephone Number	:	708-839-9947
Fax Number	:	708-839-9947

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	03/07/2013

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Directions to “ MRS. PAMELA M BANDA MSCCCSLPL” Practice Location

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