Healthcare Provider Details

I. General information

NPI: 1366094328
Provider Name (Legal Business Name): AMANDA STAGG PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E 5TH AVE STE 235
NAPERVILLE IL
60563-3194
US

IV. Provider business mailing address

300 E 5TH AVE STE 235
NAPERVILLE IL
60563-3194
US

V. Phone/Fax

Practice location:
  • Phone: 630-937-3362
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.010030
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: