Provider Demographics
NPI:1316212392
Name:WALWORTH, AMANNDA A
Entity type:Individual
Prefix:MS
First Name:AMANNDA
Middle Name:A
Last Name:WALWORTH
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 1:8115 164TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1118
Mailing Address - Country:US
Mailing Address - Phone:718-380-3000
Mailing Address - Fax:718-380-9475
Practice Address - Street 1:8115 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1118
Practice Address - Country:US
Practice Address - Phone:718-380-3000
Practice Address - Fax:718-380-9475
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093066104100000X
NY0788691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker