Provider Demographics
NPI:1902580764
Name:KING, AMANDA (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 N 90TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3616
Mailing Address - Country:US
Mailing Address - Phone:262-720-3739
Mailing Address - Fax:
Practice Address - Street 1:12720 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4637
Practice Address - Country:US
Practice Address - Phone:262-785-1500
Practice Address - Fax:262-785-1555
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10392125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty