Provider Demographics
NPI:1063722494
Name:VAN DE MOTTER, AMY BETH (LCSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:BETH
Last Name:VAN DE MOTTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4507
Mailing Address - Country:US
Mailing Address - Phone:434-960-6292
Mailing Address - Fax:
Practice Address - Street 1:1115 E MOREHEAD ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2886
Practice Address - Country:US
Practice Address - Phone:979-670-4584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0077531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical