Provider Demographics
NPI:1184822587
Name:FLUDD, AMANDA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:FLUDD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:CRICHLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:381 SUNRISE HWY STE 602
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3006
Mailing Address - Country:US
Mailing Address - Phone:347-868-7813
Mailing Address - Fax:718-264-4620
Practice Address - Street 1:381 SUNRISE HWY STE 602
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3006
Practice Address - Country:US
Practice Address - Phone:718-208-3914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074608-1104100000X
NY0810571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1184822587Medicaid