Provider Demographics
NPI:1144484387
Name:HARDIN, AMANDA JO (NCSP)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JO
Last Name:HARDIN
Suffix:
Gender:F
Credentials:NCSP
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:STATECZNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NCSP
Mailing Address - Street 1:4801 W EL CAMINITO DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-6414
Mailing Address - Country:US
Mailing Address - Phone:210-387-7520
Mailing Address - Fax:
Practice Address - Street 1:4801 W EL CAMINITO DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-6414
Practice Address - Country:US
Practice Address - Phone:210-387-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4021737103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool