Healthcare Provider Details

I. General information

NPI: 1821396219
Provider Name (Legal Business Name): AMANDA JEAN DAVIS GLEIM LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 03/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 16TH AVE N
NAMPA ID
83687-4058
US

IV. Provider business mailing address

211 16TH AVE N PO BOX 9
NAMPA ID
83653-0009
US

V. Phone/Fax

Practice location:
  • Phone: 406-210-5481
  • Fax:
Mailing address:
  • Phone: 406-210-5481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6662
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-LCPC-LIC-23179
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: