Provider Demographics
NPI:1770197790
Name:BRUNETTE, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BRUNETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 JOHNSON DR APT 506
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-3483
Mailing Address - Country:US
Mailing Address - Phone:630-301-8901
Mailing Address - Fax:
Practice Address - Street 1:4330 SHAWNEE MISSION PKWY STE 2180
Practice Address - Street 2:
Practice Address - City:FAIRWAY
Practice Address - State:KS
Practice Address - Zip Code:66205-2522
Practice Address - Country:US
Practice Address - Phone:913-588-6973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS02892103TC0700X
103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist