Healthcare Provider Details

I. General information

NPI: 1972425247
Provider Name (Legal Business Name): AMANDA GAIL PAGE SMITH LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 NORTH MAIN ST.
WALNUT COVE NC
27052
US

IV. Provider business mailing address

PO BOX 11321
WINSTON SALEM NC
27116-1321
US

V. Phone/Fax

Practice location:
  • Phone: 336-310-6727
  • Fax:
Mailing address:
  • Phone: 336-310-6727
  • Fax: 336-228-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP024078
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: