MEDICARE: AMANDA COONEY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PS01710	RI

General Provider Information

NPI Number	:	1952876526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA COONEY PH.D.

Provider Business Mailing Address
First Line	:	2515 OLD QUARRY RD APT 1314
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-2759
Country	:	US
Telephone Number	:	917-975-6145
Fax Number	:

Provider Business Practice Location Address
First Line	:	2515 OLD QUARRY RD APT 1314
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-2759
Country	:	US
Telephone Number	:	917-975-6145
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2018
Last Update Date	:	10/09/2018

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