Healthcare Provider Details

I. General information

NPI: 1205389491
Provider Name (Legal Business Name): AMANDA M SMITH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 05/28/2024
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 COLORADO BLVD STE 102
DENTON TX
76210-6872
US

IV. Provider business mailing address

PO BOX 99213
FORT WORTH TX
76199-0213
US

V. Phone/Fax

Practice location:
  • Phone: 940-484-4311
  • Fax: 940-484-5075
Mailing address:
  • Phone: 682-885-1860
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number37443
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: