Provider Demographics
NPI:1992133458
Name:TAYLOR, AMANDA BATES (LCSW, CSOTP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:BATES
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LCSW, CSOTP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:143 RIDGEWAY DR STE 111
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3495
Mailing Address - Country:US
Mailing Address - Phone:337-366-0896
Mailing Address - Fax:
Practice Address - Street 1:143 RIDGEWAY DR STE 111
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3495
Practice Address - Country:US
Practice Address - Phone:337-366-0896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-21
Last Update Date:2019-08-13
Deactivation Date:2019-07-26
Deactivation Code:
Reactivation Date:2019-08-13
Provider Licenses
StateLicense IDTaxonomies
LA122391041C0700X, 1041S0200X
VA0812000689104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker