Provider Demographics
NPI:1457849705
Name:MCDONALD, AMANDA S (LICSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:MCDONALD
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 1:2356 UNIVERSITY AVE W STE 430
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1860
Mailing Address - Country:US
Mailing Address - Phone:612-436-4840
Mailing Address - Fax:612-436-2606
Practice Address - Street 1:649 DAYTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6631
Practice Address - Country:US
Practice Address - Phone:612-436-4840
Practice Address - Fax:612-436-2604
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN220871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical