Provider Demographics
NPI:1083858294
Name:AHEARN, AMANDA ALYSE (BA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ALYSE
Last Name:AHEARN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 HUDSON ST
Mailing Address - Street 2:APT 1E
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-6606
Mailing Address - Country:US
Mailing Address - Phone:201-370-9227
Mailing Address - Fax:
Practice Address - Street 1:415 HUDSON ST
Practice Address - Street 2:APT 1E
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-6606
Practice Address - Country:US
Practice Address - Phone:201-370-9227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ100840104101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health