Provider Demographics
NPI:1912326638
Name:DEYOUNG, AMANDA NICOLE (MA)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:NICOLE
Last Name:DEYOUNG
Suffix:
Gender:F
Credentials:MA
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 1014
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-1014
Mailing Address - Country:US
Mailing Address - Phone:208-861-1051
Mailing Address - Fax:
Practice Address - Street 1:1705 W RESSEGUIE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-3934
Practice Address - Country:US
Practice Address - Phone:208-861-1051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4741101YP2500X
1-13-14177103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional