Provider Demographics
NPI:1558092585
Name:JOHNSON-KENNEHAN, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JOHNSON-KENNEHAN
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 1:131 TUPELO WAY
Mailing Address - Street 2:
Mailing Address - City:GUYTON
Mailing Address - State:GA
Mailing Address - Zip Code:31312-0017
Mailing Address - Country:US
Mailing Address - Phone:215-630-2494
Mailing Address - Fax:
Practice Address - Street 1:131 TUPELO WAY
Practice Address - Street 2:
Practice Address - City:GUYTON
Practice Address - State:GA
Practice Address - Zip Code:31312-0017
Practice Address - Country:US
Practice Address - Phone:215-630-2494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst