Healthcare Provider Details

I. General information

NPI: 1184353013
Provider Name (Legal Business Name): AMANDA KOFMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 S 4TH ST
COLUMBIA MO
65201-4226
US

IV. Provider business mailing address

25 S 4TH ST
COLUMBIA MO
65201-4226
US

V. Phone/Fax

Practice location:
  • Phone: 573-415-8903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: