Provider Demographics
NPI:1710413604
Name:WEYRUM, AMANDA R
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:WEYRUM
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:PO BOX 16906
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-6906
Mailing Address - Country:US
Mailing Address - Phone:602-279-1427
Mailing Address - Fax:602-279-1431
Practice Address - Street 1:11666 N 28TH DR
Practice Address - Street 2:UNIT 165
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-5616
Practice Address - Country:US
Practice Address - Phone:602-279-1427
Practice Address - Fax:602-279-1431
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7653883104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ7653883OtherDCS/OLR LICENSING AUTHORITY