Healthcare Provider Details

I. General information

NPI: 1841799822
Provider Name (Legal Business Name): AMANDA MARIE KLATCH LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6729 MYRTLE AVE
GLENDALE NY
11385-7063
US

IV. Provider business mailing address

6433 79TH ST
MIDDLE VILLAGE NY
11379-2307
US

V. Phone/Fax

Practice location:
  • Phone: 718-456-7001
  • Fax:
Mailing address:
  • Phone: 646-275-6640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number099402
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: