Provider Demographics
NPI:1972888584
Name:WOOLLARD, AMANDA L (LCPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:WOOLLARD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:SUPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8539 TALMA CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-3633
Mailing Address - Country:US
Mailing Address - Phone:618-604-8326
Mailing Address - Fax:314-730-6585
Practice Address - Street 1:4121 UNION RD STE 219
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1070
Practice Address - Country:US
Practice Address - Phone:314-730-6787
Practice Address - Fax:314-730-6585
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013012287101YP2500X
IL180007838101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional