Provider Demographics
NPI:1366099012
Name:KOUMALATS, AMANDA MAXEY (MRC, LPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAXEY
Last Name:KOUMALATS
Suffix:
Gender:F
Credentials:MRC, LPC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:BOLTON
Other - Last Name:MAXEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3014 SW 26TH AVE STE 4000
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-3175
Mailing Address - Country:US
Mailing Address - Phone:682-478-6365
Mailing Address - Fax:
Practice Address - Street 1:3014 SW 26TH AVE STE 4000
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-3175
Practice Address - Country:US
Practice Address - Phone:682-478-6365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty