Healthcare Provider Details

I. General information

NPI: 1407577968
Provider Name (Legal Business Name): AMANDA R BRETTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2022
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 JOHNNY MARLOW RD
FAIRVIEW NC
28730-9641
US

IV. Provider business mailing address

76 JOHNNY MARLOW RD
FAIRVIEW NC
28730-9641
US

V. Phone/Fax

Practice location:
  • Phone: 828-551-7571
  • Fax:
Mailing address:
  • Phone: 828-551-7571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-30634
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number2022-9757-01
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP021851
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: