Healthcare Provider Details

I. General information

NPI: 1831542497
Provider Name (Legal Business Name): AMANDA FREDERICK-GALVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17740 PRESTON RD # 100-C
DALLAS TX
75252-5736
US

IV. Provider business mailing address

17740 PRESTON RD # 100-C
DALLAS TX
75252-5736
US

V. Phone/Fax

Practice location:
  • Phone: 469-623-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number73123
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12884
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: