Provider Demographics
NPI:1952522450
Name:MACKIE, AMANDA LEATHERMAN (LICSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEATHERMAN
Last Name:MACKIE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3032
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-3032
Mailing Address - Country:US
Mailing Address - Phone:507-344-3360
Mailing Address - Fax:
Practice Address - Street 1:306 BYRON ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3846
Practice Address - Country:US
Practice Address - Phone:507-344-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical