| Doctor Name: | AMANDA TADLOCK |
| NPI Number: | 1659701829 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | ED.S., M.A. |
| License Number: | 0701005494 |
| Business Practice Address: | 3965 Fish Hatchery Rd Gaston, SC - 290539038 |
| Business Phone Number: | 8037552261 |
| Business Fax Number: | |
| Mailing Address: | 301 Palmetto Park Blvd, LEXINGTON |
| State: | SC |
| Postal Code: | 290727872 |
| Phone Number: | 8039961500 |
| Fax Number: | |
| NPI Enumeration Date: | 11/25/2013 |
| NPI Last Update Date: | 11/25/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | 0701005494 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | VA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |