MEDICARE: MS. AMANDA S PERKINS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149017533	IL

General Provider Information

NPI Number	:	1861568958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMANDA S PERKINS LCSW

Provider Business Mailing Address
First Line	:	78 SPRINGDALE RD
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-2445
Country	:	US
Telephone Number	:	331-725-0067
Fax Number	:

Provider Business Practice Location Address
First Line	:	78 SPRINGDALE RD
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-2445
Country	:	US
Telephone Number	:	331-725-0067
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	04/03/2016

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