Provider Demographics
NPI:1992042477
Name:CONKLIN, AMANDA MARIE
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:MARIE
Last Name:CONKLIN
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 1:3523 AMBER DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-2905
Mailing Address - Country:US
Mailing Address - Phone:408-515-6383
Mailing Address - Fax:
Practice Address - Street 1:237 RACE ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-4823
Practice Address - Country:US
Practice Address - Phone:408-971-9822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst