Provider Demographics
NPI:1164809034
Name:BASHI, AMANDA NICOLE
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:NICOLE
Last Name:BASHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 WESTHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3026
Mailing Address - Country:US
Mailing Address - Phone:607-205-8541
Mailing Address - Fax:
Practice Address - Street 1:136 WESTHAVEN RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3026
Practice Address - Country:US
Practice Address - Phone:607-205-8541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY103033104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health