MEDICARE: AMANDA RENEE HART CC, LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA00023855	WA
2	101YM0800X	Mental Health Counselor	CL61519127	WA

General Provider Information

NPI Number	:	1164699013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA RENEE HART CC, LMT

Provider Business Mailing Address
First Line	:	1105 15TH AVE STE F
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-3080
Country	:	US
Telephone Number	:	360-703-6499
Fax Number	:	360-838-9902

Provider Business Practice Location Address
First Line	:	1105 15TH AVE STE F
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-3080
Country	:	US
Telephone Number	:	360-703-6499
Fax Number	:	360-838-9902

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2008
Last Update Date	:	05/09/2024

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