Basic Information
| Provider Information | |||||||||
| NPI: | 1235798299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | KATE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 ASHLEY AVE RM 202 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294258905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437929162 | ||||||||
| FaxNumber: | 8437929163 | ||||||||
| Practice Location | |||||||||
| Address1: | 861 MSC | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294251009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437929162 | ||||||||
| FaxNumber: | 8437929163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2019 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | LL82817 | SC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | LL82817 | 01 | SC | LIMITED MEDICAL LICENSE | OTHER |