Healthcare Provider Details

I. General information

NPI: 1770197790
Provider Name (Legal Business Name): AMANDA BRUNETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/08/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 SHAWNEE MISSION PKWY STE 2180
FAIRWAY KS
66205-2522
US

IV. Provider business mailing address

6201 JOHNSON DR APT 506
MISSION KS
66202-3483
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-6973
  • Fax:
Mailing address:
  • Phone: 630-301-8901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number02892
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: