Provider Demographics
NPI:1932374584
Name:MUNGO, AMANI AMANDA (LPC)
Entity Type:Individual
Prefix:DR
First Name:AMANI
Middle Name:AMANDA
Last Name:MUNGO
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 1:1830 WATER PL SE STE 215
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-7407
Mailing Address - Country:US
Mailing Address - Phone:470-326-6469
Mailing Address - Fax:678-853-2466
Practice Address - Street 1:1830 WATER PL SE STE 215
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-7407
Practice Address - Country:US
Practice Address - Phone:470-326-6469
Practice Address - Fax:678-853-2466
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004810101YP2500X
GALPC004810101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004810OtherGEORGIA LICENSURE BOARD
GALPC004810Medicaid