Provider Demographics
NPI:1023587524
Name:KELLEY, AMANDA H (LCSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:H
Last Name:KELLEY
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-0509
Mailing Address - Country:US
Mailing Address - Phone:870-538-5414
Mailing Address - Fax:870-538-5412
Practice Address - Street 1:110 N DREW ST
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:AR
Practice Address - Zip Code:71667
Practice Address - Country:US
Practice Address - Phone:870-628-5110
Practice Address - Fax:855-854-6281
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7724-C1041C0700X
AR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty