Provider Demographics
NPI:1104216001
Name:NEZAT, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NEZAT
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 1:12201A TYSON CV
Mailing Address - Street 2:DUPLEX A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5310
Mailing Address - Country:US
Mailing Address - Phone:512-644-6926
Mailing Address - Fax:
Practice Address - Street 1:100 TOBY TRL
Practice Address - Street 2:
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-5249
Practice Address - Country:US
Practice Address - Phone:512-642-4076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58240102769104100000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1104216001Medicaid