Provider Demographics
NPI:1407577968
Name:BRETTILLO, AMANDA R
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:BRETTILLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 JOHNNY MARLOW RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NC
Mailing Address - Zip Code:28730-9641
Mailing Address - Country:US
Mailing Address - Phone:828-551-7571
Mailing Address - Fax:
Practice Address - Street 1:76 JOHNNY MARLOW RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:NC
Practice Address - Zip Code:28730-9641
Practice Address - Country:US
Practice Address - Phone:828-551-7571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-30634101YA0400X
NC2022-9757-01175T00000X
347C00000X
NCP0218511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No347C00000XTransportation ServicesPrivate VehicleGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCM2024-9757-01OtherNORTH CAROLINA PEER SUPPORT SPECIALIST
NCP021851OtherLCSWA LICENSE
NC40422193Medicaid
NC2022-9757-01OtherNC DIVISON OF MENTAL HEALTH,DEVELOPMETAL DISABILITIES AND SUBSTANCE ABUSE