Healthcare Provider Details

I. General information

NPI: 1205357712
Provider Name (Legal Business Name): AMANDA CATHERINE WISNIEWSKI LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 FALLSWAY
BALTIMORE MD
21202-4800
US

IV. Provider business mailing address

421 FALLSWAY
BALTIMORE MD
21202-4800
US

V. Phone/Fax

Practice location:
  • Phone: 410-703-1108
  • Fax:
Mailing address:
  • Phone: 410-703-1108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number26490
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: