Provider Demographics
NPI:1275039588
Name:VITAL, AMANDA EVETTE (BGS, MAT, EDS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:EVETTE
Last Name:VITAL
Suffix:
Gender:F
Credentials:BGS, MAT, EDS
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:EVETTE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BGS, MAT,EDS
Mailing Address - Street 1:1409 KIRKMAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5344
Mailing Address - Country:US
Mailing Address - Phone:337-419-3586
Mailing Address - Fax:855-239-9737
Practice Address - Street 1:1409 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5344
Practice Address - Country:US
Practice Address - Phone:337-419-3586
Practice Address - Fax:855-239-9737
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty