Provider Demographics
NPI:1164699013
Name:HART, AMANDA RENEE (CC, LMT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:HART
Suffix:
Gender:F
Credentials:CC, LMT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:RENEE
Other - Last Name:DOCKSTEADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1105 15TH AVE STE F
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3080
Mailing Address - Country:US
Mailing Address - Phone:360-703-6499
Mailing Address - Fax:360-838-9902
Practice Address - Street 1:1105 15TH AVE STE F
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3080
Practice Address - Country:US
Practice Address - Phone:360-703-6499
Practice Address - Fax:360-838-9902
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023855225700000X
WACL61519127101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist