Provider Demographics
NPI:1710351069
Name:MACKEAN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MACKEAN
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 1:6824 LOGUE LN
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-7241
Mailing Address - Country:US
Mailing Address - Phone:254-327-2001
Mailing Address - Fax:
Practice Address - Street 1:36 S KINNELOA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3853
Practice Address - Country:US
Practice Address - Phone:626-844-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician