Provider Demographics
NPI:1487948634
Name:BANTLE, AMANDA (LCSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BANTLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 CABIN CREEK CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3023
Mailing Address - Country:US
Mailing Address - Phone:618-789-2527
Mailing Address - Fax:
Practice Address - Street 1:21350 W 153RD ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5413
Practice Address - Country:US
Practice Address - Phone:913-322-2400
Practice Address - Fax:913-621-5730
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS8013104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker