=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013277524
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. AMANDA LAUREN CASSIDY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2012
-----------------------------------------------------
Last Update Date | 07/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2951 LANDOVER ST
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22305-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-657-7472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2951 LANDOVER ST
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22305-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-657-7472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number | 0133000838
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------