Healthcare Provider Details

I. General information

NPI: 1841765096
Provider Name (Legal Business Name): AMANDA MARIE SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

3115 S GRAND BLVD STE 450
SAINT LOUIS MO
63118-1045
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1000
  • Fax:
Mailing address:
  • Phone: 314-577-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2017008697
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: