Provider Demographics
NPI:1225441736
Name:JUSTICE, AMANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JUSTICE
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 1:730 HAWTHORNE LN
Mailing Address - Street 2:SUITE 267
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2633 WEST BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-6705
Practice Address - Country:US
Practice Address - Phone:704-521-4977
Practice Address - Fax:704-521-8541
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0096981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical