Healthcare Provider Details

I. General information

NPI: 1730511569
Provider Name (Legal Business Name): AMANDA KAY WURST LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2013
Last Update Date: 08/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 5TH AVE STE 205
NAPERVILLE IL
60563-8965
US

IV. Provider business mailing address

109 CRESCENT LN
SCHAUMBURG IL
60193-5712
US

V. Phone/Fax

Practice location:
  • Phone: 630-779-0751
  • Fax:
Mailing address:
  • Phone: 303-325-4047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149015863
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: