Provider Demographics
NPI:1578878617
Name:WAXHAM, AMY DANIELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DANIELLE
Last Name:WAXHAM
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 1:1955 LONG BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-5501
Mailing Address - Country:US
Mailing Address - Phone:562-533-4942
Mailing Address - Fax:562-317-3144
Practice Address - Street 1:1955 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-5501
Practice Address - Country:US
Practice Address - Phone:562-533-4942
Practice Address - Fax:562-317-3144
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW34056104100000X
CA834201041C0700X
CALCSW834201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker