Healthcare Provider Details

I. General information

NPI: 1104156850
Provider Name (Legal Business Name): AMANDA BLACKBURN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 MCCALLIE AVE
CHATTANOOGA TN
37404-3026
US

IV. Provider business mailing address

1815 MCCALLIE AVE
CHATTANOOGA TN
37404-3026
US

V. Phone/Fax

Practice location:
  • Phone: 425-375-6289
  • Fax: 423-756-2899
Mailing address:
  • Phone: 423-756-2894
  • Fax: 423-756-2899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC2540
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: