Provider Demographics
NPI:1609404599
Name:GITOMER, AMANDA LORELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LORELLE
Last Name:GITOMER
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 1:7856 ALLEN RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-9782
Mailing Address - Country:US
Mailing Address - Phone:631-245-9909
Mailing Address - Fax:
Practice Address - Street 1:5395 ESTATE OFFICE DR STE 15395
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0614
Practice Address - Country:US
Practice Address - Phone:901-232-1956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-28
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN63641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical