=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346898442
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA MICHELE RIDDLE LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2019
-----------------------------------------------------
Last Update Date | 05/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3595 E FOUNTAIN BLVD STE 130
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80910-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-839-3991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6611 E CENTRAL AVE STE C
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-1937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-393-2447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 3074
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT.0002097
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------