Provider Demographics
NPI:1245796580
Name:STUDENT, AMANDA (LCSW, DSW)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:STUDENT
Suffix:
Gender:F
Credentials:LCSW, DSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WOODLAWN RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-4223
Mailing Address - Country:US
Mailing Address - Phone:914-774-6919
Mailing Address - Fax:
Practice Address - Street 1:2 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4223
Practice Address - Country:US
Practice Address - Phone:914-774-6919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0858341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1245796580Medicaid