Provider Demographics
NPI:1669818803
Name:CRUIKSHANK, AMANDA LYN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYN
Last Name:CRUIKSHANK
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 1:1129 E GERMAN STREET EXT
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-3909
Mailing Address - Country:US
Mailing Address - Phone:315-868-3568
Mailing Address - Fax:
Practice Address - Street 1:310 MAIN ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-1236
Practice Address - Country:US
Practice Address - Phone:315-792-9039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0944551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical