Healthcare Provider Details

I. General information

NPI: 1609263896
Provider Name (Legal Business Name): AMANDA MAYOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2015
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 E BEECHTREE LN
WAYNE PA
19087-3404
US

IV. Provider business mailing address

224 E BEECHTREE LN
WAYNE PA
19087-3404
US

V. Phone/Fax

Practice location:
  • Phone: 610-585-6445
  • Fax:
Mailing address:
  • Phone: 610-585-6445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC014343
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCP3336-R
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC008128
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: