Provider Demographics
NPI:1487957783
Name:AMY D. FOSTER
Entity type:Organization
Organization Name:AMY D. FOSTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:DIACHENKO
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPA
Authorized Official - Phone:336-223-4606
Mailing Address - Street 1:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-0723
Mailing Address - Country:US
Mailing Address - Phone:336-223-4606
Mailing Address - Fax:
Practice Address - Street 1:2554 LEWISVILLE CLEMMONS RD STE 303
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8749
Practice Address - Country:US
Practice Address - Phone:336-223-5060
Practice Address - Fax:855-726-7734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 1041C0700X
NC3555251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty