Provider Demographics
NPI:1659701829
Name:TADLOCK, AMANDA (EDS, MA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:TADLOCK
Suffix:
Gender:F
Credentials:EDS, MA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BADGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS, MA
Mailing Address - Street 1:301 PALMETTO PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7872
Mailing Address - Country:US
Mailing Address - Phone:803-996-1500
Mailing Address - Fax:
Practice Address - Street 1:3965 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:GASTON
Practice Address - State:SC
Practice Address - Zip Code:29053-9038
Practice Address - Country:US
Practice Address - Phone:803-755-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005494101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health