Provider Demographics
NPI:1184344087
Name:DETIBERIIS, AMANDA (LMSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DETIBERIIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1286
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-1286
Mailing Address - Country:US
Mailing Address - Phone:631-744-0207
Mailing Address - Fax:631-744-3565
Practice Address - Street 1:525 NY-25A
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778
Practice Address - Country:US
Practice Address - Phone:631-744-0207
Practice Address - Fax:631-744-3565
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116969104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker