Provider Demographics
NPI:1821555293
Name:FREDERICK, AMANDA L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:L
Last Name:FREDERICK
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 1:2283 HIGHWAY 348
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38828-9016
Mailing Address - Country:US
Mailing Address - Phone:662-231-7397
Mailing Address - Fax:
Practice Address - Street 1:2283 HIGHWAY 348
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38828-9016
Practice Address - Country:US
Practice Address - Phone:662-231-7397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC82701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical