Provider Demographics
NPI:1104170240
Name:CAMPOS, AMANDA MYERS (PSYD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MYERS
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 SCEPTER LN
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-2902
Mailing Address - Country:US
Mailing Address - Phone:205-370-5156
Mailing Address - Fax:
Practice Address - Street 1:2408 SCEPTER LN
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35226-2902
Practice Address - Country:US
Practice Address - Phone:205-370-5156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL1996103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01261511Medicaid