Healthcare Provider Details

I. General information

NPI: 1114592805
Provider Name (Legal Business Name): AMANDA E BADDMOCCOSIN-BARNES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA KAZIK

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E GREEN BAY ST STE 101
SHAWANO WI
54166-2444
US

IV. Provider business mailing address

407 W VINAL ST
WITTENBERG WI
54499-9280
US

V. Phone/Fax

Practice location:
  • Phone: 715-280-8130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12439-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: