Provider Demographics
NPI:1699595777
Name:LEIBOVITZ, AMANDA PATRICIA (PHD, LPC, LMHC, CMPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:PATRICIA
Last Name:LEIBOVITZ
Suffix:
Gender:F
Credentials:PHD, LPC, LMHC, CMPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 BRASSTOWN CT
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:SC
Mailing Address - Zip Code:29670-1877
Mailing Address - Country:US
Mailing Address - Phone:847-571-8406
Mailing Address - Fax:
Practice Address - Street 1:508 BRASSTOWN CT
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:SC
Practice Address - Zip Code:29670-1877
Practice Address - Country:US
Practice Address - Phone:847-571-8406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61357194101YM0800X
SC9114101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional