1770765471 NPI number — AMANDA GAIL CONERLY MS, MSCE, LPC, NCC

Table of content: AMANDA GAIL CONERLY MS, MSCE, LPC, NCC (NPI 1770765471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770765471 NPI number — AMANDA GAIL CONERLY MS, MSCE, LPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONERLY
Provider First Name:
AMANDA
Provider Middle Name:
GAIL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, MSCE, LPC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONERLY
Provider Other First Name:
MANDA
Provider Other Middle Name:
GAIL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, MSCE, LPC, NCC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1770765471
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39350-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-650-8150
Provider Business Mailing Address Fax Number:
601-429-9281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
907 CARTER AVE STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39350-3645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-663-2288
Provider Business Practice Location Address Fax Number:
601-429-9281
Provider Enumeration Date:
12/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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