Individual
AMANDA DOMANGUE BOURG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHD
Contact information
Practice address
171 BANK ST # 221, TELLICO PLAINS, TN 37385-4987
(443) 379-0447
Mailing address
PO BOX 221, TELLICO PLAINS, TN 37385-0221
Taxonomy
Speciality
Code
Description
License number
State
103TC1900X
Counseling Psychologist
Primary
3783
TN
103TC1900X
Counseling Psychologist
915
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3783
STATE PSYCHOLOGY LICENSURE
TN
01
—
915
STATE PSYCHOLOGY LICENSE
LA
Enumeration date
08/18/2006
Last updated
10/13/2022
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