Provider Demographics
NPI:1558850982
Name:AMMERMAN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:AMMERMAN
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 1:43 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08068-1232
Mailing Address - Country:US
Mailing Address - Phone:609-316-0195
Mailing Address - Fax:609-353-1549
Practice Address - Street 1:43 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:PEMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08068-1232
Practice Address - Country:US
Practice Address - Phone:609-316-0195
Practice Address - Fax:609-353-1549
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRBT-18-54529106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician