Healthcare Provider Details

I. General information

NPI: 1306190202
Provider Name (Legal Business Name): AMANDA WISIAN LPC, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10160 W 50TH AVE UNIT 4
WHEAT RIDGE CO
80033-2339
US

IV. Provider business mailing address

8181 E TUFTS AVE STE 560
DENVER CO
80237-2559
US

V. Phone/Fax

Practice location:
  • Phone: 720-669-3470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberRN.1659896
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0011133
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number1659896
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRN.1659896
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7142009-6004
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLH 60290236
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0011133
License Number StateCO
# 8
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0998730
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: