Provider Demographics
NPI:1811605363
Name:ROSE, AMANDA COURTNEY (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:COURTNEY
Last Name:ROSE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 SAGE MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-7851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3460 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:SKANEATELES
Practice Address - State:NY
Practice Address - Zip Code:13152-0017
Practice Address - Country:US
Practice Address - Phone:315-217-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019589103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical