Healthcare Provider Details

I. General information

NPI: 1295123552
Provider Name (Legal Business Name): AMANDA M WILLS PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-7051
US

IV. Provider business mailing address

P O BOX 357051 NASNI COMMANDER NAVAL AIR FORCES
SAN DIEGO CA
92135-7051
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2252
  • Fax:
Mailing address:
  • Phone: 619-545-1148
  • Fax: 619-767-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005128
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810005128
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: