Provider Demographics
NPI:1669116240
Name:SWACK, AMANDA (CSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SWACK
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 SPRING RUN ST
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1803
Mailing Address - Country:US
Mailing Address - Phone:859-625-2249
Mailing Address - Fax:859-251-4347
Practice Address - Street 1:163 SPRING RUN ST
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1803
Practice Address - Country:US
Practice Address - Phone:859-625-2249
Practice Address - Fax:859-251-4347
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
KY2558551041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool