Healthcare Provider Details

I. General information

NPI: 1699015321
Provider Name (Legal Business Name): AMANDA BLAIR CARLIN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2013
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 BEAUVOIR AVE EATING DISORDERS PROGRAM, MACII-SUITE 200
SUMMIT NJ
07901-3533
US

IV. Provider business mailing address

99 BEAUVOIR AVE EATING DISORDERS PROGRAM, MACII-SUITE 200
SUMMIT NJ
07901-3533
US

V. Phone/Fax

Practice location:
  • Phone: 908-598-6620
  • Fax: 908-522-5779
Mailing address:
  • Phone: 908-598-6620
  • Fax: 908-522-5779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35SI00503800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: