MEDICARE: AMANDA MANSKE LCSW, RPT

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	1041C0700X	Clinical Social Worker	SW19170	FL

General Provider Information

NPI Number	:	1649985334
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA MANSKE LCSW, RPT

Provider Business Mailing Address
First Line	:	826 SW MAIN BLVD STE 102
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-5742
Country	:	US
Telephone Number	:	386-984-5366
Fax Number	:	386-287-6525

Provider Business Practice Location Address
First Line	:	826 SW MAIN BLVD STE 102
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-5742
Country	:	US
Telephone Number	:	386-984-5366
Fax Number	:

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

Provider Enumeration Date	:	01/18/2023
Last Update Date	:	09/11/2023

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