Healthcare Provider Details

I. General information

NPI: 1891242913
Provider Name (Legal Business Name): AMANDA WAGER MSW, MHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 NE 94TH STREET
SEATTLE WA
98115-2727
US

IV. Provider business mailing address

15622 36TH AVE NE
LAKE FOREST PARK WA
98155-6616
US

V. Phone/Fax

Practice location:
  • Phone: 206-461-4580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: