Healthcare Provider Details

I. General information

NPI: 1982123485
Provider Name (Legal Business Name): AMANDA COURTENAY MANCHACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5473 BLAIR RD STE 100
DALLAS TX
75231-4227
US

IV. Provider business mailing address

5473 BLAIR RD STE 100
DALLAS TX
75231-4227
US

V. Phone/Fax

Practice location:
  • Phone: 972-904-9039
  • Fax:
Mailing address:
  • Phone: 972-904-9039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number56379
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: