Healthcare Provider Details

I. General information

NPI: 1841012739
Provider Name (Legal Business Name): AMANDA NICOLE BENTON LCSWA, LCASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 TOWNCENTER DR STE 825
CLEMMONS NC
27012-9376
US

IV. Provider business mailing address

4055 HEATHER VIEW LN
WINSTON SALEM NC
27127-4517
US

V. Phone/Fax

Practice location:
  • Phone: 704-980-9186
  • Fax:
Mailing address:
  • Phone: 336-470-4475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-30321
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP021543
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number18357
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: