Provider Demographics
NPI:1710254834
Name:MESSINA, AMANDA C
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:MESSINA
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 1:5303 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-1021
Mailing Address - Country:US
Mailing Address - Phone:414-445-0997
Mailing Address - Fax:414-445-0989
Practice Address - Street 1:5303 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208
Practice Address - Country:US
Practice Address - Phone:414-445-0997
Practice Address - Fax:414-445-0989
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3000-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100020246Medicaid