MEDICARE: MRS. AMANDA MARIE ROOT MS

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	101Y00000X	Counselor	#PPC-501	WY
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	997	KS
3	101YP2500X	Professional Counselor	2339	KS

General Provider Information

NPI Number	:	1871822965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA MARIE ROOT MS

Provider Business Mailing Address
First Line	:	2420 N WOODLAWN BLVD STE 300
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67220-3960
Country	:	US
Telephone Number	:	316-347-7157
Fax Number	:

Provider Business Practice Location Address
First Line	:	2420 N WOODLAWN BLVD STE 300
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67220-3960
Country	:	US
Telephone Number	:	316-347-7157
Fax Number	:

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

Provider Enumeration Date	:	12/18/2009
Last Update Date	:	12/09/2024

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