Provider Demographics
NPI:1992121677
Name:DEDIEGO, AMANDA (PHD, LPC, NCC, BC-TM)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:DEDIEGO
Suffix:
Gender:F
Credentials:PHD, LPC, NCC, BC-TM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W 1ST ST STE 208A
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 W 1ST ST STE 208A
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2480
Practice Address - Country:US
Practice Address - Phone:307-234-7419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CO0018339101YP2500X
WY2047101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor