Provider Demographics
NPI:1932706710
Name:KONTOR, AMANDA B
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:KONTOR
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 1:4706 ANDOVER CT APT 16C
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-1491
Mailing Address - Country:US
Mailing Address - Phone:219-670-9829
Mailing Address - Fax:
Practice Address - Street 1:4706 ANDOVER CT APT 16C
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-1491
Practice Address - Country:US
Practice Address - Phone:219-670-9829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33009702A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN33009702AMedicaid