Provider Demographics
NPI:1578638193
Name:HARTMAN, AMANDA GRACE SCOTT (LCSWR)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:GRACE SCOTT
Last Name:HARTMAN
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 OAK ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1652
Mailing Address - Country:US
Mailing Address - Phone:315-882-1958
Mailing Address - Fax:315-295-2526
Practice Address - Street 1:530 OAK ST
Practice Address - Street 2:SUITE 204
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1652
Practice Address - Country:US
Practice Address - Phone:315-882-1958
Practice Address - Fax:315-295-2526
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0761731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249154Medicaid
NY02249154Medicaid