Provider Demographics
NPI:1891242913
Name:WAGER, AMANDA (MSW, MHP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WAGER
Suffix:
Gender:F
Credentials:MSW, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15622 36TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-6616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 NE 94TH STREET
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2727
Practice Address - Country:US
Practice Address - Phone:206-461-4580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness