Provider Demographics
NPI:1417326687
Name:WISSLER, AMANDA JANE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:JANE
Last Name:WISSLER
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 1:6749 N 2200 W APT B103
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-8305
Mailing Address - Country:US
Mailing Address - Phone:801-448-8264
Mailing Address - Fax:
Practice Address - Street 1:2078 PROSPECTOR AVE STE 1
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7587
Practice Address - Country:US
Practice Address - Phone:801-448-8264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5869457-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical