Provider Demographics
NPI:1558048140
Name:WOOD, AMANDA ROSE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:WOOD
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 1:80 TIPTON DR E
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3617
Mailing Address - Country:US
Mailing Address - Phone:631-433-8018
Mailing Address - Fax:
Practice Address - Street 1:20 BROADHOLLOW RD STE 3011
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2502
Practice Address - Country:US
Practice Address - Phone:718-626-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool