MEDICARE: AMANDA DIMARTINI MA, LPC

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	101YP2500X	Professional Counselor	2010042210	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	002283881	OTHER	MO	CHILDREN'S TREATMENT SERVICES

General Provider Information

NPI Number	:	1811288558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA DIMARTINI MA, LPC

Provider Business Mailing Address
First Line	:	3543 S LONE PINE AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-4854
Country	:	US
Telephone Number	:	417-379-4781
Fax Number	:

Provider Business Practice Location Address
First Line	:	3543 S LONE PINE AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-4854
Country	:	US
Telephone Number	:	417-379-4781
Fax Number	:

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

Provider Enumeration Date	:	04/28/2011
Last Update Date	:	01/05/2015

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