Healthcare Provider Details

I. General information

NPI: 1598598104
Provider Name (Legal Business Name): AMANDA HURST EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 DOWLING ST
KENDALLVILLE IN
46755-9407
US

IV. Provider business mailing address

3409 FAWN CREEK BLVD
WATERLOO IN
46793-0087
US

V. Phone/Fax

Practice location:
  • Phone: 260-347-5236
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number10190118
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: