Healthcare Provider Details

I. General information

NPI: 1295699163
Provider Name (Legal Business Name): AMANDA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 BROOKSHIRE CRK
PHILADELPHIA PA
19116-1207
US

IV. Provider business mailing address

198 BROOKSHIRE CRK
PHILADELPHIA PA
19116-1207
US

V. Phone/Fax

Practice location:
  • Phone: 215-779-0462
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC018085
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: