Healthcare Provider Details

I. General information

NPI: 1770632556
Provider Name (Legal Business Name): AMANDA SUE FREDERICK MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12581 DALLAS LANE
CABOOL MO
65689
US

IV. Provider business mailing address

PO BOX 714
CABOOL MO
65689-0714
US

V. Phone/Fax

Practice location:
  • Phone: 417-926-8054
  • Fax:
Mailing address:
  • Phone: 417-926-8054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2005027056
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2005027056
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: