Provider Demographics
NPI:1720664527
Name:COZAR, AMANDA TIFFANY (SUDPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:TIFFANY
Last Name:COZAR
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5716 ARCARRO CT SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-7157
Mailing Address - Country:US
Mailing Address - Phone:360-970-8131
Mailing Address - Fax:
Practice Address - Street 1:1116 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2831
Practice Address - Country:US
Practice Address - Phone:206-323-0930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60563128390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program