Healthcare Provider Details

I. General information

NPI: 1912326638
Provider Name (Legal Business Name): AMANDA NICOLE DEYOUNG M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 W RESSEGUIE ST
BOISE ID
83702-3934
US

IV. Provider business mailing address

PO BOX 1014
BOISE ID
83701-1014
US

V. Phone/Fax

Practice location:
  • Phone: 208-861-1051
  • Fax:
Mailing address:
  • Phone: 208-861-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-4741
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-14177
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: