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General NPI Number Information
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NPI Number | 1104337195
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Entity Type | Organization
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Legal Business Name | AMANDA GABRIELLE KACENA, LLC
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Dates
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Enumeration Date | 10/17/2017
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Last Update Date | 10/17/2017
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Provider Practice Location Address
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Address Line | 2005 VALPARAISO ST STE 106
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City | VALPARAISO
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State | IN
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Zip | 46383-3330
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Country | US
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Telephone | 312-590-7140
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Fax |
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Provider Business Mailing Address
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Address Line | 4101 BRENTWOOD DR
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City | VALPARAISO
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State | IN
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Zip | 46383-1373
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Country | US
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Telephone | 312-590-7140
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMANDA GABRIELLE KACENA
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Credential | LCSW
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Telephone | 312-590-7140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 39001619A
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License Number State | IN
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