Healthcare Provider Details

I. General information

NPI: 1134526304
Provider Name (Legal Business Name): AMANDA SERIE LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 N MAIN ST
KOKOMO IN
46901-4622
US

IV. Provider business mailing address

322 N MAIN ST
KOKOMO IN
46901-4622
US

V. Phone/Fax

Practice location:
  • Phone: 765-453-8555
  • Fax: 765-453-8020
Mailing address:
  • Phone: 765-453-8555
  • Fax: 765-453-8020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33006613A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: