Provider Demographics
NPI:1982573606
Name:KOENNICKE, AMANDA (MA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KOENNICKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 CROSS RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-8856
Mailing Address - Country:US
Mailing Address - Phone:802-487-7801
Mailing Address - Fax:
Practice Address - Street 1:53 CROSS ROAD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:VT
Practice Address - Zip Code:05829
Practice Address - Country:US
Practice Address - Phone:802-487-7801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-31
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT097.0133085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty