Provider Demographics
NPI:1538445465
Name:MADENBERG, AMY WEST (LMSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:WEST
Last Name:MADENBERG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 NORWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1959
Mailing Address - Country:US
Mailing Address - Phone:516-446-0532
Mailing Address - Fax:
Practice Address - Street 1:823 W JERICHO TPKE
Practice Address - Street 2:SUITE 1C
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3216
Practice Address - Country:US
Practice Address - Phone:631-864-1477
Practice Address - Fax:631-543-0654
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065666-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical