Provider Demographics
NPI:1639897812
Name:FELLERER, AMANDA ROSELLE (LPC-IT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ROSELLE
Last Name:FELLERER
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-1309
Mailing Address - Country:US
Mailing Address - Phone:920-918-7236
Mailing Address - Fax:
Practice Address - Street 1:1407 N 8TH ST STE 202
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3400
Practice Address - Country:US
Practice Address - Phone:920-547-4544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4605-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional