Provider Demographics
NPI:1407103088
Name:PENN, AMANDA ROSE (MA)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ROSE
Last Name:PENN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ROSE
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 GILLHAM RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-234-3000
Mailing Address - Fax:816-302-9939
Practice Address - Street 1:5808 W 110TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-2504
Practice Address - Country:US
Practice Address - Phone:913-696-8000
Practice Address - Fax:816-302-9939
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS101YP2500X
222Q00000X
MA9080101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSLCPC03458OtherLCPC