Provider Demographics
NPI:1447758693
Name:ANHALT, AMANDA MARIE (LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:ANHALT
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-1926
Mailing Address - Country:US
Mailing Address - Phone:920-980-7801
Mailing Address - Fax:
Practice Address - Street 1:1011 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4006
Practice Address - Country:US
Practice Address - Phone:920-459-3173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16200-132101YA0400X
WI8860-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI16200-132OtherCLINICAL SUBSTANCE ABUSE COUNSELOR
WI8860-123OtherLICENSED CLINICAL SOCIAL WORKER