Basic Information
| Provider Information | |||||||||
| NPI: | 1427301191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKNELLY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | CCDCIII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 S PRAIRIE AVE | ||||||||
| Address2: | |||||||||
| City: | TEA | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570643216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053224079 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2412 S CLIFF AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571054031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053224079 | ||||||||
| FaxNumber: | 6053224080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2012 | ||||||||
| LastUpdateDate: | 10/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11091490 | SD | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.