Provider Demographics
NPI:1376907717
Name:EZOLD, AMANDA MAE
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:MAE
Last Name:EZOLD
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 1:10920 AVANA WAY APT 3-307
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-5099
Mailing Address - Country:US
Mailing Address - Phone:508-985-8924
Mailing Address - Fax:
Practice Address - Street 1:321 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-1750
Practice Address - Country:US
Practice Address - Phone:508-478-0207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist