Healthcare Provider Details

I. General information

NPI: 1033455324
Provider Name (Legal Business Name): AMANDA L GRAGG LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 N 12TH ST
MILWAUKEE WI
53233-1308
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-773-4312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4828
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4828125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: