Provider Demographics
NPI:1588362891
Name:TAYLOR, AMANDA JANE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JANE
Other - Last Name:VISCARDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1808 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-9349
Mailing Address - Country:US
Mailing Address - Phone:574-849-8737
Mailing Address - Fax:
Practice Address - Street 1:217 N WATER AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2825
Practice Address - Country:US
Practice Address - Phone:888-692-6590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor