Provider Demographics
NPI:1740717958
Name:KENNEDY, AMANDA NICHOLE (LCSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICHOLE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:NICHOLE
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:674 CANARY ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63021-4313
Mailing Address - Country:US
Mailing Address - Phone:314-703-9899
Mailing Address - Fax:
Practice Address - Street 1:15740 S OUTER 40 RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2004
Practice Address - Country:US
Practice Address - Phone:636-237-4053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170080371041C0700X
MO20190434231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical