Healthcare Provider Details

I. General information

NPI: 1265895767
Provider Name (Legal Business Name): AMANDA ICENHOWER MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8495 CRATER LAKE HWY 11CM
WHITE CITY OR
97503-3011
US

IV. Provider business mailing address

8495 CRATER LAKE HWY
WHITE CITY OR
97503-3011
US

V. Phone/Fax

Practice location:
  • Phone: 541-826-2111
  • Fax:
Mailing address:
  • Phone: 541-826-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7414
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberA4107
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: