Healthcare Provider Details

I. General information

NPI: 1700647658
Provider Name (Legal Business Name): AMANDA JANE BOOTHE MSW, LICSW, AADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA JANE LILLY

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOWE ST
BECKLEY WV
25801-5509
US

IV. Provider business mailing address

108 MCCLURE ST
BECKLEY WV
25801-6040
US

V. Phone/Fax

Practice location:
  • Phone: 601-207-4049
  • Fax:
Mailing address:
  • Phone: 681-422-9682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00946732
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: