Provider Demographics
NPI:1568930386
Name:SMITH, AMANDA N
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:N
Last Name:SMITH
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 1:143 SUGAR MILL CIR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-9431
Mailing Address - Country:US
Mailing Address - Phone:912-785-9027
Mailing Address - Fax:877-515-6711
Practice Address - Street 1:143 SUGAR MILL CIR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-9431
Practice Address - Country:US
Practice Address - Phone:912-785-9027
Practice Address - Fax:877-515-6711
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-18-70086106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician