Provider Demographics
NPI:1669807855
Name:HIETPAS, AMANDA KAYE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAYE
Last Name:HIETPAS
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 1:1119 W KENNEDY AVE
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:WI
Mailing Address - Zip Code:54136-2214
Mailing Address - Country:US
Mailing Address - Phone:920-470-0754
Mailing Address - Fax:
Practice Address - Street 1:1119 W KENNEDY AVE
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136-2214
Practice Address - Country:US
Practice Address - Phone:920-470-0754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
WI7638-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional