Provider Demographics
NPI:1043414071
Name:GROLLER, AMANDA BETH (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BETH
Last Name:GROLLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-1737
Mailing Address - Country:US
Mailing Address - Phone:409-763-2373
Mailing Address - Fax:
Practice Address - Street 1:4444 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-1737
Practice Address - Country:US
Practice Address - Phone:409-763-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61748101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor