Healthcare Provider Details

I. General information

NPI: 1508142977
Provider Name (Legal Business Name): AMANDA MEGAN YOUNG NIBBER LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 OLD HIGHWAY 64
BOLIVAR TN
38008-3587
US

IV. Provider business mailing address

10710 OLD HIGHWAY 64
BOLIVAR TN
38008-3587
US

V. Phone/Fax

Practice location:
  • Phone: 731-658-6113
  • Fax: 731-658-1597
Mailing address:
  • Phone: 731-658-6113
  • Fax: 731-658-1597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0144351
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0217321
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC7580
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: