Provider Demographics
NPI:1487465779
Name:WILSON, AMANDA J (LCSW)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:J
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1525 POPHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-7225
Mailing Address - Country:US
Mailing Address - Phone:929-356-4341
Mailing Address - Fax:
Practice Address - Street 1:1525 POPHAM AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-7225
Practice Address - Country:US
Practice Address - Phone:929-356-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY37633101YA0400X
NY113012104100000X
NY0992001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker