| Doctor Name: | DR. AMANDA SURDOCK |
| NPI Number: | 1093118754 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PH.D. |
| License Number: | 54-947 |
| Business Practice Address: | 5779 Getwell Rd Building D: Ste 3 Southaven, MS - 386726347 |
| Business Phone Number: | 6625106507 |
| Business Fax Number: | 6625106508 |
| Mailing Address: | 5779 Getwell Rd, Building D: Ste 3 SOUTHAVEN |
| State: | MS |
| Postal Code: | 386726347 |
| Phone Number: | 6625106507 |
| Fax Number: | 6625106508 |
| NPI Enumeration Date: | 10/08/2014 |
| NPI Last Update Date: | 10/08/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 54-947 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |