Healthcare Provider Details

I. General information

NPI: 1336059054
Provider Name (Legal Business Name): AMANDA CROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 VALLEY RD
CANON CITY CO
81212-4291
US

IV. Provider business mailing address

465 VALLEY RD
CANON CITY CO
81212-4291
US

V. Phone/Fax

Practice location:
  • Phone: 719-458-8050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: