Provider Demographics
NPI:1770632556
Name:FREDERICK, AMANDA SUE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MSW, 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 714
Mailing Address - Street 2:
Mailing Address - City:CABOOL
Mailing Address - State:MO
Mailing Address - Zip Code:65689-0714
Mailing Address - Country:US
Mailing Address - Phone:417-926-8054
Mailing Address - Fax:
Practice Address - Street 1:12581 DALLAS LANE
Practice Address - Street 2:
Practice Address - City:CABOOL
Practice Address - State:MO
Practice Address - Zip Code:65689
Practice Address - Country:US
Practice Address - Phone:417-926-8054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050270561041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker