Healthcare Provider Details

I. General information

NPI: 1437219011
Provider Name (Legal Business Name): AMANDA ROSE O'BRIEN MILLEISEN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PROSPECT ST STE 4-7
RIDGEWOOD NJ
07450-4404
US

IV. Provider business mailing address

4714 GETTYSBURG RD LEGAL DEPARTMENT
MECHANICSBURG PA
17055-4325
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-2242
  • Fax: 201-447-4377
Mailing address:
  • Phone: 717-972-1100
  • Fax: 717-975-9981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35S100454100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: