Provider Demographics
NPI:1275222788
Name:WILLIAMS, AMANDA (LSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7240
Mailing Address - Country:US
Mailing Address - Phone:701-639-3295
Mailing Address - Fax:
Practice Address - Street 1:5122 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7240
Practice Address - Country:US
Practice Address - Phone:701-639-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372500000X, 3747P1801X, 376J00000X, 376J00000X
ND6782104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No372500000XNursing Service Related ProvidersChore Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Yes376J00000XNursing Service Related ProvidersHomemaker