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NPI Code Detail

MEDICARE: AMANDA M REGIS LICSW

MEDICARE: AMANDA M REGIS LICSW
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
1101YA0400XAddiction (Substance Use Disorder) Counselor151.0134039VT
21041C0700XClinical Social Worker089.0110736VT

General Provider Information

NPI Number : 1700352762
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMANDA M REGIS LICSW
Provider Business Mailing Address
First Line : PO BOX 318
Second Line :
City : BRADFORD
State : VT
Zip : 05033-0318
Country : US
Telephone Number : 802-222-9317
Fax Number : 802-222-4818
Provider Business Practice Location Address
First Line : 437 S MAIN ST
Second Line :
City : BRADFORD
State : VT
Zip : 05033-9196
Country : US
Telephone Number : 802-222-9317
Fax Number : 802-222-4818
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/17/2018
Last Update Date : 10/17/2018

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