Basic Information
| Provider Information | |||||||||
| NPI: | 1245719764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 SEPAL ST | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275766676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193068024 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 MACKENAN DR | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275117903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193712848 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2018 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.