Provider Demographics
NPI:1265974802
Name:BATES, AMANDA (MS ED)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 694
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46624-0694
Mailing Address - Country:US
Mailing Address - Phone:574-406-1808
Mailing Address - Fax:
Practice Address - Street 1:1251 N EDDY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1479
Practice Address - Country:US
Practice Address - Phone:574-406-1808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10136107171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor