Provider Demographics
NPI:1467902791
Name:SMITH, AMANDA JUNE (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JUNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-0548
Mailing Address - Country:US
Mailing Address - Phone:618-833-8551
Mailing Address - Fax:
Practice Address - Street 1:204 SOUTH ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1549
Practice Address - Country:US
Practice Address - Phone:618-833-8551
Practice Address - Fax:618-833-2911
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490146801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical