Healthcare Provider Details

I. General information

NPI: 1790176097
Provider Name (Legal Business Name): AMANDA JOSEPHINE LEE DEGNER ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 SARAH CT
RINEYVILLE KY
40162-8602
US

IV. Provider business mailing address

125 SARAH CT
RINEYVILLE KY
40162-8602
US

V. Phone/Fax

Practice location:
  • Phone: 229-343-1822
  • Fax:
Mailing address:
  • Phone: 229-343-1822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC007588
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number169075
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: