Provider Demographics
NPI:1083893457
Name:WADLEY, AMANDA JANE (MS, LPC)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:JANE
Last Name:WADLEY
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MAGNOLIA PL
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30461-4248
Mailing Address - Country:US
Mailing Address - Phone:912-587-7201
Mailing Address - Fax:
Practice Address - Street 1:102 S ZETTEROWER AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4816
Practice Address - Country:US
Practice Address - Phone:912-764-6731
Practice Address - Fax:912-764-6789
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005012101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health