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General NPI Number Information
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NPI Number | 1497521835
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Entity Type | Individual
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Provider Name | AMANDA MOUDRY
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Gender | Female
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Dates
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Enumeration Date | 11/28/2023
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Last Update Date | 11/28/2023
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Provider Practice Location Address
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Address Line | 1754 N WASHINGTON ST STE 104A
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City | NAPERVILLE
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State | IL
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Zip | 60563-1462
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Country | US
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Telephone | 708-736-0654
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Fax |
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Provider Business Mailing Address
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Address Line | 1613 LAUREL LN
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City | DARIEN
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State | IL
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Zip | 60561-5327
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Country | US
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Telephone | 630-824-7769
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 178.017896
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License Number State | IL
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