Provider Demographics
NPI:1104516970
Name:DORMAN, AMANDA B (MS, QMHP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:DORMAN
Suffix:
Gender:F
Credentials:MS, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-2812
Mailing Address - Country:US
Mailing Address - Phone:253-883-7951
Mailing Address - Fax:
Practice Address - Street 1:1037 W STATE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2812
Practice Address - Country:US
Practice Address - Phone:253-883-7951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251S00000XAgenciesCommunity/Behavioral Health