Healthcare Provider Details

I. General information

NPI: 1700409794
Provider Name (Legal Business Name): AMANDA SUN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 05/25/2020
Certification Date: 05/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 KENILWORTH DR STE 100
TOWSON MD
21204-2142
US

IV. Provider business mailing address

1122 KENILWORTH DR STE 100
TOWSON MD
21204-2142
US

V. Phone/Fax

Practice location:
  • Phone: 425-233-9573
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: AMANDA YUAN SUN
Title or Position: PSYCHIATRIST
Credential: MD
Phone: 425-233-9573