Provider Demographics
NPI:1750897716
Name:ANDERSON, AMANDA MARY (LPC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S98W12878 LOOMIS RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-4907
Mailing Address - Country:US
Mailing Address - Phone:414-403-5372
Mailing Address - Fax:
Practice Address - Street 1:10201 W LINCOLN AVE STE 308
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2136
Practice Address - Country:US
Practice Address - Phone:414-329-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6729-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional