Healthcare Provider Details

I. General information

NPI: 1235570904
Provider Name (Legal Business Name): AMANDA GROTHOUSE MSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S 3RD ST
BOONVILLE IN
47601-1723
US

IV. Provider business mailing address

415 MULBERRY ST
EVANSVILLE IN
47713-1230
US

V. Phone/Fax

Practice location:
  • Phone: 812-897-4776
  • Fax: 812-422-7558
Mailing address:
  • Phone: 812-423-4418
  • Fax: 812-422-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34007179A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: