=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851183388
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA TIMOTEO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2025
-----------------------------------------------------
Last Update Date | 05/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2231 RIDGE RD STE 101
-----------------------------------------------------
City | ROCKWALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75087-5150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-415-8220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 132 PLEASANT HILL LN
-----------------------------------------------------
City | FATE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75189-5022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-415-8220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 51959
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------