Provider Demographics
NPI:1396963294
Name:MCCONNELL, AMANDA SHANKS (LCSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SHANKS
Last Name:MCCONNELL
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 1:1750 17TH ST
Mailing Address - Street 2:SUITE J-2
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34234-8632
Mailing Address - Country:US
Mailing Address - Phone:941-552-2078
Mailing Address - Fax:941-552-2079
Practice Address - Street 1:1750 17TH ST
Practice Address - Street 2:SUITE J-2
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34234-8632
Practice Address - Country:US
Practice Address - Phone:941-552-2078
Practice Address - Fax:941-552-2079
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC051989001041C0700X
FLSW93141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGE584AMedicare UPIN
128150Q0AMedicare UPIN