Provider Demographics
NPI:1750683553
Name:CUSHING, AMANDA (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CUSHING
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4503 DUCK POND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05819-4530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 CEDAR LANE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VT
Practice Address - Zip Code:05828
Practice Address - Country:US
Practice Address - Phone:802-684-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900719501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1019321Medicaid
VT2267901Medicare UPIN