Provider Demographics
NPI:1679395016
Name:WEBB, AMANDA JO (SAC-IT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:WEBB
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:BLACKHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1340 MARIA DR
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-1141
Mailing Address - Country:US
Mailing Address - Phone:715-630-1548
Mailing Address - Fax:
Practice Address - Street 1:210 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-5543
Practice Address - Country:US
Practice Address - Phone:855-540-5806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20695-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)