Provider Demographics
NPI:1104561828
Name:EGLESTON, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:EGLESTON
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 1:817 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-3918
Mailing Address - Country:US
Mailing Address - Phone:714-872-6977
Mailing Address - Fax:
Practice Address - Street 1:2115 STEPHENS PL STE G
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-2134
Practice Address - Country:US
Practice Address - Phone:512-940-1168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84381101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health