Provider Demographics
NPI:1467098780
Name:VESELY, AMANDA (LMSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VESELY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 HASTINGS AVE
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-3215
Mailing Address - Country:US
Mailing Address - Phone:607-321-5356
Mailing Address - Fax:
Practice Address - Street 1:1100 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5254
Practice Address - Country:US
Practice Address - Phone:607-321-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY116132104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program