Provider Demographics
NPI:1326569666
Name:IBANEZ, AMANDA GAYLE (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GAYLE
Last Name:IBANEZ
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 1:605 AUSTIN AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76701-2048
Mailing Address - Country:US
Mailing Address - Phone:254-722-6958
Mailing Address - Fax:
Practice Address - Street 1:150 HILLCREST MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8897
Practice Address - Country:US
Practice Address - Phone:254-202-4056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX572251041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health