Provider Demographics
NPI:1114763562
Name:COWAN, AMANDA VIRGINIA
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:VIRGINIA
Last Name:COWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ARBOR LN
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-2529
Mailing Address - Country:US
Mailing Address - Phone:631-278-9677
Mailing Address - Fax:
Practice Address - Street 1:235 BLUE POINT AVE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1261
Practice Address - Country:US
Practice Address - Phone:631-363-5794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator