Provider Demographics
NPI:1326460312
Name:PERCIVAL, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PERCIVAL
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:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73702-0146
Mailing Address - Country:US
Mailing Address - Phone:405-426-7434
Mailing Address - Fax:
Practice Address - Street 1:1420 W OWEN K GARRIOTT RD
Practice Address - Street 2:BLDG 1
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5751
Practice Address - Country:US
Practice Address - Phone:580-744-9811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6399101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional