Provider Demographics
NPI:1245713965
Name:SHOCK, AMANDA JOY (CCLS, DT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOY
Last Name:SHOCK
Suffix:
Gender:F
Credentials:CCLS, DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8468 E 350 N
Mailing Address - Street 2:
Mailing Address - City:PIERCETON
Mailing Address - State:IN
Mailing Address - Zip Code:46562-9106
Mailing Address - Country:US
Mailing Address - Phone:317-965-1216
Mailing Address - Fax:
Practice Address - Street 1:8468 E 350 N
Practice Address - Street 2:
Practice Address - City:PIERCETON
Practice Address - State:IN
Practice Address - Zip Code:46562-9106
Practice Address - Country:US
Practice Address - Phone:317-965-1216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist