=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831567700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMANDA HOWARD PILESKI, PHD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2015
-----------------------------------------------------
Last Update Date | 12/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 851 HIGHWAY 441 S STE 105
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30525-6264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-782-1237
-----------------------------------------------------
Fax | 404-393-0737
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 851 HIGHWAY 441 S STE 105
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30525-6264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-782-1237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AMANDA PILESKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-782-1237
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY003905
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------