Provider Demographics
NPI:1124183637
Name:AMEDEO, MARY (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:AMEDEO
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1039
Mailing Address - Country:US
Mailing Address - Phone:805-234-0948
Mailing Address - Fax:844-740-0060
Practice Address - Street 1:118 NEVADA ST
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2610
Practice Address - Country:US
Practice Address - Phone:805-234-0948
Practice Address - Fax:844-740-0060
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2121041C0700X
CALCSW291181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80003692Medicaid
NHRE3470Medicare ID - Type Unspecified