Provider Demographics
NPI:1427301191
Name:MCKNELLY, AMANDA GRACE (CCDCIII)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE
Last Name:MCKNELLY
Suffix:
Gender:F
Credentials:CCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064-3216
Mailing Address - Country:US
Mailing Address - Phone:605-322-4079
Mailing Address - Fax:
Practice Address - Street 1:2412 S CLIFF AVE
Practice Address - Street 2:STE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4031
Practice Address - Country:US
Practice Address - Phone:605-322-4079
Practice Address - Fax:605-322-4080
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11091490101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)