Healthcare Provider Details

I. General information

NPI: 1881098226
Provider Name (Legal Business Name): AMANDA SUE MALONE CAC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2014
Last Update Date: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 23RD AVE SUITE A
LONGMONT CO
80501-1114
US

IV. Provider business mailing address

850 23RD AVE SUITE A
LONGMONT CO
80501-1114
US

V. Phone/Fax

Practice location:
  • Phone: 303-245-0123
  • Fax: 30-245-0119
Mailing address:
  • Phone: 303-245-0123
  • Fax: 303-245-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACC.0020826
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: