Provider Demographics
NPI:1578180642
Name:WACKER, AMANDA RENEE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:WACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FUZZY TAIL DR
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-4885
Mailing Address - Country:US
Mailing Address - Phone:571-432-6780
Mailing Address - Fax:
Practice Address - Street 1:611 W JUBAL EARLY DR STE C
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-6501
Practice Address - Country:US
Practice Address - Phone:884-244-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician