MEDICARE: AMANDA DUFOUR CSW, LCADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	278317	KY
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	104100000X	Social Worker	257182	KY

General Provider Information

NPI Number	:	1477162105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA DUFOUR CSW, LCADC

Provider Business Mailing Address
First Line	:	PO BOX 2141
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40588-2141
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2220 EXECUTIVE DR STE 102
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40505-4871
Country	:	US
Telephone Number	:	859-309-8737
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2020
Last Update Date	:	05/25/2023

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