Healthcare Provider Details

I. General information

NPI: 1306329081
Provider Name (Legal Business Name): AMANDA MACK RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2499 S CAPITAL OF TEXAS HWY BLDG B
AUSTIN TX
78746-7762
US

IV. Provider business mailing address

3100 PREMIER DR STE 234
IRVING TX
75063-2693
US

V. Phone/Fax

Practice location:
  • Phone: 512-732-2511
  • Fax:
Mailing address:
  • Phone: 972-756-1222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberRBT-15-08263
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: