Provider Demographics
NPI:1376250522
Name:NIELSEN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 MAIN ST APT B
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:PA
Mailing Address - Zip Code:18641-2234
Mailing Address - Country:US
Mailing Address - Phone:570-313-9347
Mailing Address - Fax:
Practice Address - Street 1:70 MAIN ST
Practice Address - Street 2:
Practice Address - City:LUZERNE
Practice Address - State:PA
Practice Address - Zip Code:18709-1210
Practice Address - Country:US
Practice Address - Phone:570-762-6358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health