Provider Demographics
NPI:1578818381
Name:BYRD, AMANDA RUTH (CADC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:RUTH
Last Name:BYRD
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 W BROADWAY ST STE G
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2902
Mailing Address - Country:US
Mailing Address - Phone:208-524-7400
Mailing Address - Fax:
Practice Address - Street 1:2275 W BROADWAY ST STE G
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2902
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
ID10278101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)