Provider Demographics
NPI:1730379496
Name:SAND, AMANDA LU
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LU
Last Name:SAND
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 1:103 NAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:MOSSYROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98564-9507
Mailing Address - Country:US
Mailing Address - Phone:253-255-6307
Mailing Address - Fax:360-736-3139
Practice Address - Street 1:2428 W REYNOLDS AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4554
Practice Address - Country:US
Practice Address - Phone:360-330-9044
Practice Address - Fax:360-736-3139
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00058719101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health