Healthcare Provider Details

I. General information

NPI: 1407341837
Provider Name (Legal Business Name): AMANDA PANG FOUA MOUA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 XERXES AVE N
MINNEAPOLIS MN
55411-2851
US

IV. Provider business mailing address

1501 XERXES AVE N
MINNEAPOLIS MN
55411-2851
US

V. Phone/Fax

Practice location:
  • Phone: 612-977-3236
  • Fax: 612-521-3893
Mailing address:
  • Phone: 763-521-3477
  • Fax: 763-521-3893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4152565
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: