Provider Demographics
NPI:1891043998
Name:REYOME, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:REYOME
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 1:1774 BEACON ST
Mailing Address - Street 2:APT. 5
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-2056
Mailing Address - Country:US
Mailing Address - Phone:219-310-6137
Mailing Address - Fax:
Practice Address - Street 1:1575 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2122
Practice Address - Country:US
Practice Address - Phone:617-296-0061
Practice Address - Fax:617-296-5408
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1305638Medicaid