Provider Demographics
NPI:1124601802
Name:FATH, AMANDA (LMSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FATH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 US HIGHWAY 380 STE 500
Mailing Address - Street 2:#183
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-0176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17237 CEDAR ROCK CT UNIT B
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-9499
Practice Address - Country:US
Practice Address - Phone:940-735-1462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX680951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical