Healthcare Provider Details

I. General information

NPI: 1760614705
Provider Name (Legal Business Name): AMANDA L THOMPSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2009
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR STE 2201
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-0767
  • Fax: 571-472-0377
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY1000568
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810004239
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: