Provider Demographics
NPI:1396154704
Name:FOREMAN, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:FOREMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 OLD SOUTH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4120
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:636-246-1008
Practice Address - Street 1:6440 S LEWIS AVE STE 2200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1060
Practice Address - Country:US
Practice Address - Phone:918-712-0859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210114861041C0700X
104100000X
OK58911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746170GMedicaid