Healthcare Provider Details

I. General information

NPI: 1750683553
Provider Name (Legal Business Name): AMANDA CUSHING MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 CEDAR LANE
DANVILLE VT
05828
US

IV. Provider business mailing address

4503 DUCK POND RD
WATERFORD VT
05819-4530
US

V. Phone/Fax

Practice location:
  • Phone: 802-684-2275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0890071950
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: