Provider Demographics
NPI:1407176613
Name:BROWN, AMANDA DISHON
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DISHON
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JEAN
Other - Last Name:DISHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3717 TAYLORSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1333
Mailing Address - Country:US
Mailing Address - Phone:502-459-5295
Mailing Address - Fax:502-452-9079
Practice Address - Street 1:3717 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1366
Practice Address - Country:US
Practice Address - Phone:502-459-5295
Practice Address - Fax:502-452-9079
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6241104100000X
KY2013-003106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker