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Provider Information for 1770632556


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AMANDA SUE FREDERICK MSW, LCSW


Sex: Female

NPI: 1770632556
Last Updated: 2007-07-08
Certification Date:

Details

NameValue
NPI1770632556
Enumeration Date2007-01-09
NPI TypeNPI-1 Individual
Sole ProprietorYES
StatusActive
Mailing Address PO BOX 714
CABOOL, MO 65689-0714
United States

Phone: 417-926-8054 | Fax:
 
Primary Practice Address 12581 DALLAS LANE
CABOOL, MO 65689
United States

Phone: 417-926-8054 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 1041C0700X - Social Worker - ClinicalMO2005027056
No 104100000X - Social Worker MO2005027056