Provider Demographics
NPI:1174845119
Name:KEPHART, AMY L (LICSW)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:L
Last Name:KEPHART
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W LAKE ST
Mailing Address - Street 2:STE 350
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2952
Mailing Address - Country:US
Mailing Address - Phone:612-979-2276
Mailing Address - Fax:651-925-0427
Practice Address - Street 1:2012 BRYANT AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2819
Practice Address - Country:US
Practice Address - Phone:347-746-0522
Practice Address - Fax:646-606-3916
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066980 1104100000X
MN280991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0669801OtherLICENSED MASTER OF SOCIAL WORK LICENSE NUMBER