Provider Demographics
NPI:1740532472
Name:ELLINGWOOD, AMANDA RENEE (BSW, MSW, LSW, ICADD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:ELLINGWOOD
Suffix:
Gender:F
Credentials:BSW, MSW, LSW, ICADD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4427 E 800 N
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:IN
Mailing Address - Zip Code:46001-8750
Mailing Address - Country:US
Mailing Address - Phone:765-748-8679
Mailing Address - Fax:
Practice Address - Street 1:4427 E 800 N
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:IN
Practice Address - Zip Code:46001-8750
Practice Address - Country:US
Practice Address - Phone:765-748-8679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0910018549104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker