Healthcare Provider Details

I. General information

NPI: 1710543509
Provider Name (Legal Business Name): AMANDA DANIELLE SMITH FIERSTEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 MIDLAND AVE STE 15B
BASALT CO
81621-8119
US

IV. Provider business mailing address

PO BOX 1115
BASALT CO
81621-1115
US

V. Phone/Fax

Practice location:
  • Phone: 970-925-5858
  • Fax:
Mailing address:
  • Phone: 970-925-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: