Healthcare Provider Details

I. General information

NPI: 1043849698
Provider Name (Legal Business Name): AMANDA JOANN DEGNER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MANDI DEGNER LPC-IT

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 N PORT WASHINGTON RD
GLENDALE WI
53212-1004
US

IV. Provider business mailing address

4655 N PORT WASHINGTON RD
GLENDALE WI
53212-1004
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-3339
  • Fax: 414-247-1875
Mailing address:
  • Phone: 414-266-3339
  • Fax: 414-247-1875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4352-226
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8772-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: