Provider Demographics
NPI:1962693325
Name:LEROUX, AMANDA S
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:S
Last Name:LEROUX
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 1:1015 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-1779
Mailing Address - Country:US
Mailing Address - Phone:573-996-4239
Mailing Address - Fax:573-996-9086
Practice Address - Street 1:1015 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1779
Practice Address - Country:US
Practice Address - Phone:573-996-4239
Practice Address - Fax:573-996-9086
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007006282235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2007006282OtherSP/LANG PATH.LICENSE