Basic Information
| Provider Information | |||||||||
| NPI: | 1043849698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEGNER | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JOANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEGNER | ||||||||
| OtherFirstName: | MANDI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC-IT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4655 N PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142663339 | ||||||||
| FaxNumber: | 4142471875 | ||||||||
| Practice Location | |||||||||
| Address1: | 4655 N PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142663339 | ||||||||
| FaxNumber: | 4142471875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2020 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 4352-226 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 8772-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 19842654 | 05 | WI | MEDICAID |