Provider Demographics
NPI:1538352463
Name:WELLER, AMANDA LEE (LMHC, CASAC)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:LEE
Last Name:WELLER
Suffix:
Gender:F
Credentials:LMHC, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 NEW LOUDON RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-4002
Mailing Address - Country:US
Mailing Address - Phone:518-783-5381
Mailing Address - Fax:
Practice Address - Street 1:636 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4002
Practice Address - Country:US
Practice Address - Phone:518-783-5381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000645101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health