Provider Demographics
NPI:1497133359
Name:SAMUDIO, AMANDA JO (LPCCCA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:SAMUDIO
Suffix:
Gender:F
Credentials:LPCCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3439 BUCKHORN DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-1716
Mailing Address - Country:US
Mailing Address - Phone:859-721-1636
Mailing Address - Fax:
Practice Address - Street 1:3439 BUCKHORN DR
Practice Address - Street 2:SUITE 160
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515-1716
Practice Address - Country:US
Practice Address - Phone:859-721-1636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCCCA00216359101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional