Provider Demographics
NPI:1538826698
Name:SMITH, AMANDA LYNN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:MA
Mailing Address - Zip Code:01749-2262
Mailing Address - Country:US
Mailing Address - Phone:774-571-9154
Mailing Address - Fax:
Practice Address - Street 1:15 SOUTH ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:MA
Practice Address - Zip Code:01749-2262
Practice Address - Country:US
Practice Address - Phone:774-571-9154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARBT-21-193914106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician