Provider Demographics
NPI:1093118754
Name:SURDOCK, AMANDA (PHD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:SURDOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12187 INGLECREST LN
Mailing Address - Street 2:
Mailing Address - City:FARRAGUT
Mailing Address - State:TN
Mailing Address - Zip Code:37934-5321
Mailing Address - Country:US
Mailing Address - Phone:901-338-1219
Mailing Address - Fax:
Practice Address - Street 1:162D MARKET PLACE BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-2337
Practice Address - Country:US
Practice Address - Phone:865-212-6600
Practice Address - Fax:865-313-2149
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS54-947103TC0700X
TN3506103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical