Healthcare Provider Details

I. General information

NPI: 1518218445
Provider Name (Legal Business Name): AMANDA G PHELAN LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA C GLENN

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5229 NEW DESIGN RD
FREDERICK MD
21703-7103
US

IV. Provider business mailing address

5229 NEW DESIGN RD
FREDERICK MD
21703-7103
US

V. Phone/Fax

Practice location:
  • Phone: 240-415-8620
  • Fax:
Mailing address:
  • Phone: 240-415-8620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15471
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: