Provider Demographics
NPI:1427558337
Name:PETRY, AMANDA JAY (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JAY
Last Name:PETRY
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 1:1180 N TOWN CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-6308
Mailing Address - Country:US
Mailing Address - Phone:775-657-1688
Mailing Address - Fax:
Practice Address - Street 1:1180 N TOWN CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6308
Practice Address - Country:US
Practice Address - Phone:775-657-1688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8638-C1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100557642Medicaid