Provider Demographics
NPI:1982042776
Name:FOX, AMANDA (BA, MHP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FOX
Suffix:
Gender:F
Credentials:BA, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IL
Mailing Address - Zip Code:62448-1736
Mailing Address - Country:US
Mailing Address - Phone:618-783-4154
Mailing Address - Fax:618-783-2339
Practice Address - Street 1:106 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IL
Practice Address - Zip Code:62448-1736
Practice Address - Country:US
Practice Address - Phone:618-783-4154
Practice Address - Fax:618-783-2339
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376001106007Medicaid
IL376001106006Medicaid
IL1992772149Medicare PIN