Provider Demographics
NPI:1063505725
Name:CANALLY, AMELIA D (LCSW)
Entity Type:Individual
Prefix:MS
First Name:AMELIA
Middle Name:D
Last Name:CANALLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2714 TETNER TRAIL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704
Mailing Address - Country:US
Mailing Address - Phone:512-799-4091
Mailing Address - Fax:
Practice Address - Street 1:3534 BEECAVE RD
Practice Address - Street 2:SUITE #114
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746
Practice Address - Country:US
Practice Address - Phone:512-799-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX351231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0009KXOtherBLUE CROSS BLUE SHIELD #