Provider Demographics
NPI:1629817192
Name:HERENDEEN, AMANDA SHAY (LSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SHAY
Last Name:HERENDEEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751
Mailing Address - Street 2:
Mailing Address - City:NORTH WEBSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46555-0751
Mailing Address - Country:US
Mailing Address - Phone:574-834-1393
Mailing Address - Fax:833-527-8322
Practice Address - Street 1:501 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORTH WEBSTER
Practice Address - State:IN
Practice Address - Zip Code:46555-0751
Practice Address - Country:US
Practice Address - Phone:574-834-1393
Practice Address - Fax:833-527-8322
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33008027A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker