Provider Demographics
NPI:1538311394
Name:BOETTCHER, AMANDA FAITH
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:FAITH
Last Name:BOETTCHER
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 1:5155 WOODFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-4124
Mailing Address - Country:US
Mailing Address - Phone:703-830-1953
Mailing Address - Fax:
Practice Address - Street 1:5155 WOODFIELD DR
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-4124
Practice Address - Country:US
Practice Address - Phone:703-830-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0-07-2282103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst