Provider Demographics
NPI:1043849698
Name:DEGNER, AMANDA JOANN (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOANN
Last Name:DEGNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MANDI
Other - Middle Name:
Other - Last Name:DEGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC-IT
Mailing Address - Street 1:4655 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1004
Mailing Address - Country:US
Mailing Address - Phone:414-266-3339
Mailing Address - Fax:414-247-1875
Practice Address - Street 1:4655 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212-1004
Practice Address - Country:US
Practice Address - Phone:414-266-3339
Practice Address - Fax:414-247-1875
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4352-226101YP2500X
WI8772-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI19842654Medicaid