Provider Demographics
NPI:1407577968
Name:BRETTILLO, AMANDA R
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:BRETTILLO
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 1:10 LANDS END DR
Mailing Address - Street 2:
Mailing Address - City:CANDLER
Mailing Address - State:NC
Mailing Address - Zip Code:28715-9198
Mailing Address - Country:US
Mailing Address - Phone:828-551-7571
Mailing Address - Fax:
Practice Address - Street 1:10 LANDS END DR
Practice Address - Street 2:
Practice Address - City:CANDLER
Practice Address - State:NC
Practice Address - Zip Code:28715-9198
Practice Address - Country:US
Practice Address - Phone:828-551-7571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X, 347C00000X
NC2022-9757-01175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or WelfareGroup - Multi-Specialty
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2022-9757-01OtherNC DIVISON OF MENTAL HEALTH,DEVELOPMETAL DISABILITIES AND SUBSTANCE ABUSE
NC40422193Medicaid