Provider Demographics
NPI:1528779808
Name:FRY, AMANDA ROSE (LSWAIC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:FRY
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 YALE AVE E APT 5
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3336
Mailing Address - Country:US
Mailing Address - Phone:360-286-9170
Mailing Address - Fax:
Practice Address - Street 1:2349 YALE AVE E APT 5
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3336
Practice Address - Country:US
Practice Address - Phone:360-286-9170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC611040951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical