=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083957963
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA E PEARSON-CARMODY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2013
-----------------------------------------------------
Last Update Date | 09/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32630 CEDAR DR UNIT A
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19967-6946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-206-0457
-----------------------------------------------------
Fax | 302-402-6100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 572
-----------------------------------------------------
City | BETHANY BEACH
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19930-0572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-206-0457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 29202
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | Q1-0000983
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------