Provider Demographics
NPI:1841732211
Name:WANNARKA, AMANDA (LICSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WANNARKA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 129TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-2384
Mailing Address - Country:US
Mailing Address - Phone:612-309-2691
Mailing Address - Fax:
Practice Address - Street 1:199 COON RAPIDS BLVD NW STE 208
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5860
Practice Address - Country:US
Practice Address - Phone:612-440-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN233821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical