Provider Demographics
NPI:1235868654
Name:KHADER, AMANDA (MED, EDS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KHADER
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 E 43RD CT
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50317-4060
Mailing Address - Country:US
Mailing Address - Phone:319-651-0603
Mailing Address - Fax:
Practice Address - Street 1:505 5TH AVE STE 600
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-2319
Practice Address - Country:US
Practice Address - Phone:800-327-4692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1041740103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool