MEDICARE: AMA AGYEMANG LCWSA

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	P020049	NC

General Provider Information

NPI Number	:	1417797598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMA AGYEMANG LCWSA

Provider Business Mailing Address
First Line	:	4316 STANDING ROCK WAY
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-1090
Country	:	US
Telephone Number	:	919-881-9650
Fax Number	:

Provider Business Practice Location Address
First Line	:	1612 ARAPAHOE RIDGE DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-9706
Country	:	US
Telephone Number	:	919-885-9424
Fax Number	:

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

Provider Enumeration Date	:	05/28/2024
Last Update Date	:	05/28/2024

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