Provider Demographics
NPI:1124799481
Name:PEASE, AMANDA (LMS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PEASE
Suffix:
Gender:F
Credentials:LMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5351
Mailing Address - Country:US
Mailing Address - Phone:309-779-2031
Mailing Address - Fax:
Practice Address - Street 1:2701 17TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5351
Practice Address - Country:US
Practice Address - Phone:309-779-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-25
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-21-56582103K00000X
IL150.105400104100000X
IL149.0249531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker