=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740656537
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA VENTA PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2015
-----------------------------------------------------
Last Update Date | 08/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SAM HOUSTON STATE UNIVERSITY 1901 AVENUE I, SUITE 290
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77341-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-294-2436
-----------------------------------------------------
Fax | 936-294-2795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | SAM HOUSTON STATE UNIVERSITY PO BOX 2447
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77341-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-294-2436
-----------------------------------------------------
Fax | 936-294-2795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 36450
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------