Provider Demographics
NPI:1821740929
Name:CLYBURN, AMANDA GWYNETH
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GWYNETH
Last Name:CLYBURN
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 1:1500 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1551
Mailing Address - Country:US
Mailing Address - Phone:516-739-7733
Mailing Address - Fax:
Practice Address - Street 1:1500 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1551
Practice Address - Country:US
Practice Address - Phone:515-739-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker