Provider Demographics
NPI:1306190202
Name:WISIAN, AMANDA (LPC, PMHNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WISIAN
Suffix:
Gender:F
Credentials:LPC, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8181 E TUFTS AVE STE 560
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-2559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10160 W 50TH AVE UNIT 4
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2339
Practice Address - Country:US
Practice Address - Phone:720-669-3470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.16598962084P0800X, 390200000X
CO00111332084P0800X, 101YP2500X
CO1659896390200000X
UT7142009-6004101YP2500X
WALH 60290236101YP2500X
CO0998730363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional