Provider Demographics
NPI:1497296511
Name:FALKERS, AMANDA J (MS, LPC, SAC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:FALKERS
Suffix:
Gender:F
Credentials:MS, LPC, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 TERRY CT
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-8806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 S BLACK RIVER ST STE 125
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-2043
Practice Address - Country:US
Practice Address - Phone:608-501-1189
Practice Address - Fax:888-928-1124
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17434-130101YA0400X
WI16419-131101YA0400X
WI6606-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1750980306OtherAGENCY NPI NUMBER
13979430OtherCAQH
WI100065211Medicaid