Healthcare Provider Details

I. General information

NPI: 1225441736
Provider Name (Legal Business Name): AMANDA JUSTICE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 WEST BLVD
CHARLOTTE NC
28208-6705
US

IV. Provider business mailing address

730 HAWTHORNE LN SUITE 267
CHARLOTTE NC
28204-2108
US

V. Phone/Fax

Practice location:
  • Phone: 704-521-4977
  • Fax: 704-521-8541
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC009698
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: