=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730564766
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA MARIE BRADFORD-KENNEY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2015
-----------------------------------------------------
Last Update Date | 08/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 W STEPHEN FOSTER AVE STE 113
-----------------------------------------------------
City | BARDSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40004-1457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-546-3312
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 W STEPHEN FOSTER AVE STE 113
-----------------------------------------------------
City | BARDSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40004-1457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-546-3312
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 254329
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 095387
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------