Healthcare Provider Details

I. General information

NPI: 1366553018
Provider Name (Legal Business Name): AMANDA WENNER MA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5586 MAIN ST STE G4
WILLIAMSVILLE NY
14221-5421
US

IV. Provider business mailing address

5586 MAIN ST STE G4
WILLIAMSVILLE NY
14221-5421
US

V. Phone/Fax

Practice location:
  • Phone: 716-474-2159
  • Fax:
Mailing address:
  • Phone: 716-474-2159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001925-02
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001925-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002510
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: