Provider Demographics
NPI:1407489859
Name:GRIFFIN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GRIFFIN
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 1163
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-1163
Mailing Address - Country:US
Mailing Address - Phone:580-768-5097
Mailing Address - Fax:
Practice Address - Street 1:9236 POLVADORE DRIVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439
Practice Address - Country:US
Practice Address - Phone:580-768-5097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKN084085894106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician