Provider Demographics
NPI:1750659215
Name:WAGERIK-FASANO, AMANDA (LMSW, CASAC-T)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:WAGERIK-FASANO
Suffix:
Gender:F
Credentials:LMSW, CASAC-T
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3911 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5110
Mailing Address - Country:US
Mailing Address - Phone:718-948-3232
Mailing Address - Fax:718-966-6605
Practice Address - Street 1:3911 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5110
Practice Address - Country:US
Practice Address - Phone:718-948-3232
Practice Address - Fax:718-966-6605
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty