MEDICARE: DR. AMANDA EMMELINE SU MD

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	2084P0800X	Psychiatry Physician	57004	KY
2	2084P0800X	Psychiatry Physician	U8594	TX

General Provider Information

NPI Number	:	1679033344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDA EMMELINE SU MD

Provider Business Mailing Address
First Line	:	5323 HARRY HINES BLVD CHILD AND ADOLESCENT PSYCHIATRY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75390-8589
Country	:	US
Telephone Number	:	214-456-4586
Fax Number	:

Provider Business Practice Location Address
First Line	:	9400 N CENTRAL EXPY STE 1304
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75231-5047
Country	:	US
Telephone Number	:	972-502-4190
Fax Number	:

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

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	02/16/2024

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