Provider Demographics
NPI:1093973679
Name:OSWALT, AMANDA MARIE (MS)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:MARIE
Last Name:OSWALT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 FULTON ST
Mailing Address - Street 2:APT 2
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-1627
Mailing Address - Country:US
Mailing Address - Phone:321-698-9915
Mailing Address - Fax:
Practice Address - Street 1:1062 FULTON ST APT 2
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1627
Practice Address - Country:US
Practice Address - Phone:321-698-9915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLO243-013-81-799-0322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLO243-013-81-799-0OtherDRIVERS LICENCE