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General NPI Number Information
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NPI Number | 1487957783
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Entity Type | Organization
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Legal Business Name | AMY D. FOSTER
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Dates
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Enumeration Date | 12/09/2010
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Last Update Date | 08/31/2022
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Provider Practice Location Address
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Address Line | 2554 LEWISVILLE CLEMMONS RD STE 303
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City | CLEMMONS
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State | NC
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Zip | 27012-8749
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Country | US
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Telephone | 336-223-5060
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Fax | 855-726-7734
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Provider Business Mailing Address
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Address Line | PO BOX 723
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City | YADKINVILLE
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State | NC
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Zip | 27055-0723
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Country | US
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Telephone | 336-223-4606
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. AMY DIACHENKO FOSTER
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Credential | MA, LPA
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Telephone | 336-223-4606
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 3555
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License Number State | NC
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