MEDICARE: AMANDA EILEEN WEIDEL PCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1164607719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA EILEEN WEIDEL PCC

Provider Business Mailing Address
First Line	:	195 DRIGGS AVE
Second Line	:	4B
City	:	BROOKLYN
State	:	NY
Zip	:	11222-4624
Country	:	US
Telephone Number	:	937-219-3446
Fax Number	:

Provider Business Practice Location Address
First Line	:	333 PARK AVE S
Second Line	:	3D
City	:	NEW YORK
State	:	NY
Zip	:	10010-2906
Country	:	US
Telephone Number	:	212-388-1903
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2008
Last Update Date	:	12/15/2009

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