Provider Demographics
NPI:1770217580
Name:GARRISON, AMANDA R (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:GARRISON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W GALAXY DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAWN
Mailing Address - State:IL
Mailing Address - Zip Code:62898-1108
Mailing Address - Country:US
Mailing Address - Phone:618-237-1060
Mailing Address - Fax:
Practice Address - Street 1:4230 LINCOLNSHIRE DR STE E
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2189
Practice Address - Country:US
Practice Address - Phone:618-242-4290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017820101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional