MEDICARE: AMY D. FOSTER

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	103T00000X	Psychologist
2	1041C0700X	Clinical Social Worker
3	251S00000X	Community/Behavioral Health Agency	3555	NC

General Provider Information

NPI Number	:	1487957783
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMY D. FOSTER

Provider Business Mailing Address
First Line	:	PO BOX 723
Second Line	:
City	:	YADKINVILLE
State	:	NC
Zip	:	27055-0723
Country	:	US
Telephone Number	:	336-223-4606
Fax Number	:

Provider Business Practice Location Address
First Line	:	2554 LEWISVILLE CLEMMONS RD STE 303
Second Line	:
City	:	CLEMMONS
State	:	NC
Zip	:	27012-8749
Country	:	US
Telephone Number	:	336-223-5060
Fax Number	:	855-726-7734

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. AMY DIACHENKO FOSTER
Credential	:	MA, LPA
Telephone Number	:	336-223-4606

Provider Enumeration Date	:	12/09/2010
Last Update Date	:	08/31/2022

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