=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043735533
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA STOVALL DOOLEY LSW, MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2017
-----------------------------------------------------
Last Update Date | 08/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1906 BELLEVIEW AVE SE
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24014-1838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-588-8735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 499 OLNEY RD
-----------------------------------------------------
City | VINTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24179-1251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-529-3860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 0903002413
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------