Provider Demographics
NPI:1295616399
Name:SMITH, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43806 410TH AVE
Mailing Address - Street 2:
Mailing Address - City:HERON LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56137-2051
Mailing Address - Country:US
Mailing Address - Phone:320-221-0391
Mailing Address - Fax:
Practice Address - Street 1:125 S SIBLEY AVE STE 5
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355-2831
Practice Address - Country:US
Practice Address - Phone:320-535-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34908104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker