Provider Demographics
NPI:1104502145
Name:HAWTHORNE, AMANDA S (LCSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:HAWTHORNE
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 1:1523 IBIS DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7381
Mailing Address - Country:US
Mailing Address - Phone:904-505-3998
Mailing Address - Fax:
Practice Address - Street 1:8130 BAYMEADOWS CIR W # 204-206
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1880
Practice Address - Country:US
Practice Address - Phone:904-608-9881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW203661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty