Provider Demographics
NPI:1104456383
Name:NASCIMENTO, AMANDA TATLOCK (MS, LCGC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:TATLOCK
Last Name:NASCIMENTO
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:I
Other - Last Name:TATLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CGC
Mailing Address - Street 1:7 RUSTIC DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-2315
Mailing Address - Country:US
Mailing Address - Phone:508-523-9725
Mailing Address - Fax:
Practice Address - Street 1:55 SAYLES ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-1729
Practice Address - Country:US
Practice Address - Phone:508-764-2400
Practice Address - Fax:508-909-7770
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
A-3628849171400000X
MAGC056170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
No171400000XOther Service ProvidersHealth & Wellness Coach