=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750897716
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA MARY ANDERSON LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2017
-----------------------------------------------------
Last Update Date | 12/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10201 W LINCOLN AVE STE 308
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-329-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | S98W12878 LOOMIS RD
-----------------------------------------------------
City | MUSKEGO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53150-4907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-403-5372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6729-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------