Provider Demographics
NPI:1982790929
Name:HALL, AMANDA DIANE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:DIANE
Last Name:HALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 N OAK STREET EXT STE C
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5910
Mailing Address - Country:US
Mailing Address - Phone:229-896-4559
Mailing Address - Fax:
Practice Address - Street 1:1905 S HUTCHINSON AVE
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-5246
Practice Address - Country:US
Practice Address - Phone:229-896-4559
Practice Address - Fax:229-896-8367
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW000828104100000X
GACSW0045081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker