Provider Demographics
NPI:1245716562
Name:WALTS, AMANDA (LCSW)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:WALTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:
Other - Last Name:WALTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:233 S ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5403
Mailing Address - Country:US
Mailing Address - Phone:607-256-2030
Mailing Address - Fax:
Practice Address - Street 1:233 S ALBANY ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5403
Practice Address - Country:US
Practice Address - Phone:607-256-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082080-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical