Healthcare Provider Details

I. General information

NPI: 1164699013
Provider Name (Legal Business Name): AMANDA RENEE HART CC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA RENEE DOCKSTEADER LMT

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 15TH AVE STE F
LONGVIEW WA
98632-3080
US

IV. Provider business mailing address

1105 15TH AVE STE F
LONGVIEW WA
98632-3080
US

V. Phone/Fax

Practice location:
  • Phone: 360-703-6499
  • Fax: 360-838-9902
Mailing address:
  • Phone: 360-703-6499
  • Fax: 360-838-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCL61519127
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00023855
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: