Provider Demographics
NPI:1720570773
Name:MOEN, AMANDA L (PHD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:MOEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-3499
Mailing Address - Country:US
Mailing Address - Phone:682-303-9200
Mailing Address - Fax:682-303-9239
Practice Address - Street 1:1300 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3499
Practice Address - Country:US
Practice Address - Phone:682-303-9200
Practice Address - Fax:682-303-9239
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38514103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist