Provider Demographics
NPI:1861013377
Name:STOCKDALE, AMANDA RUTH
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RUTH
Last Name:STOCKDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:RUTH
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 731624
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32173-1624
Mailing Address - Country:US
Mailing Address - Phone:412-496-9059
Mailing Address - Fax:
Practice Address - Street 1:109 MANATEE XING APT 306
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-1479
Practice Address - Country:US
Practice Address - Phone:412-496-9059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT-20-113858106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician