Provider Demographics
NPI:1821562000
Name:EXMAN, AMANDA (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:EXMAN
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5123 253RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:ISANTI
Mailing Address - State:MN
Mailing Address - Zip Code:55040-4203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11334 86TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4528
Practice Address - Country:US
Practice Address - Phone:763-255-2125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6343103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist