Healthcare Provider Details

I. General information

NPI: 1104313899
Provider Name (Legal Business Name): AMANDA PARK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 INDEPENDENCE PKWY STE 400
CHESAPEAKE VA
23320-5207
US

IV. Provider business mailing address

833 CREEKSIDE CRES
CHESAPEAKE VA
23320-9263
US

V. Phone/Fax

Practice location:
  • Phone: 757-420-0530
  • Fax:
Mailing address:
  • Phone: 757-202-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701007584
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: