Healthcare Provider Details

I. General information

NPI: 1144683574
Provider Name (Legal Business Name): AMANDA WAGNER PSY.D., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2016
Last Update Date: 01/01/2023
Certification Date: 01/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 E MIDLAND AVE
PARAMUS NJ
07652-2920
US

IV. Provider business mailing address

PO BOX 184
WALDWICK NJ
07463-0184
US

V. Phone/Fax

Practice location:
  • Phone: 201-921-0256
  • Fax:
Mailing address:
  • Phone: 201-921-0256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00547200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number35SI00692600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: