Healthcare Provider Details

I. General information

NPI: 1073134524
Provider Name (Legal Business Name): AMANDA IRWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 W CENTRAL AVE UNIT 2107
COOLIDGE AZ
85128-4850
US

IV. Provider business mailing address

1022 E LAUREN LN
COOLIDGE AZ
85128-9323
US

V. Phone/Fax

Practice location:
  • Phone: 520-216-7259
  • Fax:
Mailing address:
  • Phone: 520-705-1492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-18971
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number102448
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-18971
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: