Healthcare Provider Details

I. General information

NPI: 1508997891
Provider Name (Legal Business Name): AMANDA L QUINE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SWEETWATER AVE
GLENDALE AZ
85304-1505
US

IV. Provider business mailing address

26716 N 20TH LN
PHOENIX AZ
85085-1716
US

V. Phone/Fax

Practice location:
  • Phone: 602-347-2600
  • Fax: 602-347-2709
Mailing address:
  • Phone: 602-885-6212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSW2774I
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License NumberLCSW-2774
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: