Provider Demographics
NPI:1801241120
Name:EMMERT, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:EMMERT
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:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:534 PLEASANT VIEW WAY NW STE 300
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1789
Practice Address - Country:US
Practice Address - Phone:541-812-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282NR1301X, 390200000X
ORDO2040582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No282NR1301XHospitalsGeneral Acute Care HospitalRural
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program