Provider Demographics
NPI:1669136388
Name:WILLIAMS, AMANDA D
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:D
Last Name:WILLIAMS
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 1:4691 BLUFFSIDE CT
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-1200
Mailing Address - Country:US
Mailing Address - Phone:770-885-2884
Mailing Address - Fax:
Practice Address - Street 1:4691 BLUFFSIDE CT
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-1200
Practice Address - Country:US
Practice Address - Phone:770-885-2884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87-3238268103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA87-3238268Medicaid