Provider Demographics
NPI:1760800783
Name:STRADA, AMANDA NICOLE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:STRADA
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 1:176 ASHWORTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2950
Mailing Address - Country:US
Mailing Address - Phone:609-865-3092
Mailing Address - Fax:
Practice Address - Street 1:176 ASHWORTH AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-2950
Practice Address - Country:US
Practice Address - Phone:609-865-3092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY833078141103K00000X
NY2588671174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst