Provider Demographics
NPI:1508997891
Name:QUINE, AMANDA L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:L
Last Name:QUINE
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 1:26716 N 20TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-1716
Mailing Address - Country:US
Mailing Address - Phone:602-885-6212
Mailing Address - Fax:
Practice Address - Street 1:4650 W SWEETWATER AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1505
Practice Address - Country:US
Practice Address - Phone:602-347-2600
Practice Address - Fax:602-347-2709
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSW2774I1041S0200X
AZLCSW-2774251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ861791Medicaid