Provider Demographics
NPI:1225583313
Name:DELONG, AMANDA LEIGH (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:DELONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEIGH
Other - Last Name:COLLIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:800-438-1772
Mailing Address - Fax:262-293-9737
Practice Address - Street 1:3040 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2618
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-293-9737
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9309-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100060969Medicaid